Healthcare Provider Details

I. General information

NPI: 1164406369
Provider Name (Legal Business Name): JEANNIE THERESE LARSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 08/14/2020
Certification Date: 08/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9555 UPLAND LANE N
MAPLE GROVE MN
55369
US

IV. Provider business mailing address

8170 33RD AVE S P.O. BOX 1309 MAIL STOP 21110Q
MINNEAPOLIS MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-3260
  • Fax:
Mailing address:
  • Phone: 952-993-3260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number33568
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number33568
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: