Healthcare Provider Details

I. General information

NPI: 1932025574
Provider Name (Legal Business Name): THEO LARSON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2026
Last Update Date: 06/27/2026
Certification Date: 06/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 EXCELSIOR BLVD
ST LOUIS PARK MN
55426-4702
US

IV. Provider business mailing address

3121 EDGEWOOD AVE S
SAINT LOUIS PARK MN
55426-3422
US

V. Phone/Fax

Practice location:
  • Phone: 953-993-5000
  • Fax:
Mailing address:
  • Phone: 952-567-1493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number2486018
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: