Healthcare Provider Details

I. General information

NPI: 1174428007
Provider Name (Legal Business Name): ELSA ANN LARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2026
Last Update Date: 10/12/2026
Certification Date: 10/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 BROADWAY N
FARGO ND
58102-3641
US

IV. Provider business mailing address

6879 26TH ST S
FARGO ND
58104-5564
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-2147
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number206060
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: