Healthcare Provider Details

I. General information

NPI: 1710923594
Provider Name (Legal Business Name): JOYCE L LARSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 10/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 1ST AVE SE
WATERTOWN SD
57201-4402
US

IV. Provider business mailing address

506 1ST AVE SE
WATERTOWN SD
57201-4402
US

V. Phone/Fax

Practice location:
  • Phone: 605-886-8482
  • Fax: 605-884-4300
Mailing address:
  • Phone: 605-886-8482
  • Fax: 605-884-4300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9179
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1019
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: