Healthcare Provider Details

I. General information

NPI: 1932861879
Provider Name (Legal Business Name): KACI LYNN LARSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KACI KOCH PA-C

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 211699
EAGAN MN
55121-3699
US

IV. Provider business mailing address

880 SW 145TH AVE STE 202
PEMBROKE PINES FL
33027-6171
US

V. Phone/Fax

Practice location:
  • Phone: 866-849-0692
  • Fax: 888-973-8821
Mailing address:
  • Phone: 866-849-0692
  • Fax: 888-973-8821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8805
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: