Healthcare Provider Details

I. General information

NPI: 1952310237
Provider Name (Legal Business Name): BRENDA R LARSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 04/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3931 LOUISIANA AVE S
ST LOUIS PARK MN
55426-5000
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 952-993-3248
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number48944
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: