Healthcare Provider Details

I. General information

NPI: 1912987843
Provider Name (Legal Business Name): KATHLEEN LARSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 12/14/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 S BROADWAY
MINOT ND
58701-7420
US

IV. Provider business mailing address

3400 S BROADWAY
MINOT ND
58701-7420
US

V. Phone/Fax

Practice location:
  • Phone: 701-418-2600
  • Fax: 701-418-1090
Mailing address:
  • Phone: 701-418-2600
  • Fax: 701-418-2600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAC0139
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: