Healthcare Provider Details

I. General information

NPI: 1851353320
Provider Name (Legal Business Name): KEITH WILLIAM LARSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 06/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 OAKDALE AVE N
ROBBINSDALE MN
55422-2926
US

IV. Provider business mailing address

1529 IVORY CT
LAKE ELMO MN
55042-9311
US

V. Phone/Fax

Practice location:
  • Phone: 763-581-3980
  • Fax: 763-581-3591
Mailing address:
  • Phone: 651-646-3091
  • Fax: 651-646-3124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1049989
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: