Healthcare Provider Details

I. General information

NPI: 1891761664
Provider Name (Legal Business Name): TERI LEE LARSON-JOHNSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERI LEE SIGURDSON PA-C

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 09/25/2023
Certification Date: 09/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 E 1ST ST
DULUTH MN
55805-1901
US

IV. Provider business mailing address

400 E 3RD ST
DULUTH MN
55805-1951
US

V. Phone/Fax

Practice location:
  • Phone: 218-786-8364
  • Fax: 320-229-5160
Mailing address:
  • Phone: 218-786-8364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9190
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: