Healthcare Provider Details

I. General information

NPI: 1154315133
Provider Name (Legal Business Name): KATHERINE MCCOURT ROBINSON LARSON PA C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4725 36TH AVE N
CRYSTAL MN
55422-2169
US

IV. Provider business mailing address

820 SPRINGER DR
LOMBARD IL
60148-6413
US

V. Phone/Fax

Practice location:
  • Phone: 218-208-2058
  • Fax:
Mailing address:
  • Phone: 815-744-8554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9624
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: