Healthcare Provider Details

I. General information

NPI: 1689070419
Provider Name (Legal Business Name): KYLE LARSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2014
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 BERRY AVE APT 202
TOMAH WI
54660-3403
US

IV. Provider business mailing address

1028 BERRY AVE APT 202
TOMAH WI
54660-3403
US

V. Phone/Fax

Practice location:
  • Phone: 931-561-0580
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number201824-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: