Healthcare Provider Details

I. General information

NPI: 1134863764
Provider Name (Legal Business Name): DEBORAH K. LARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2022
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 N 18TH ST
BISMARCK ND
58501-2863
US

IV. Provider business mailing address

1504 N 18TH ST
BISMARCK ND
58501-2863
US

V. Phone/Fax

Practice location:
  • Phone: 701-224-8579
  • Fax:
Mailing address:
  • Phone: 701-224-8579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1473790
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: