Healthcare Provider Details

I. General information

NPI: 1710510821
Provider Name (Legal Business Name): KYLE DAVID LARSON FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2020
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 CANYON LAKE DR
RAPID CITY SD
57702-8114
US

IV. Provider business mailing address

412 E 11TH AVE
ANCHORAGE AK
99501-4507
US

V. Phone/Fax

Practice location:
  • Phone: 605-355-2500
  • Fax: 605-355-2517
Mailing address:
  • Phone: 605-770-8320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number156657
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: