MEDICARE: MRS. LISA CAROL LARSON PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	9622	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417945940
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA CAROL LARSON PAC

Provider Business Mailing Address
First Line	:	822 YELLOW BRICK RD
Second Line	:
City	:	CHASKA
State	:	MN
Zip	:	55318-2152
Country	:	US
Telephone Number	:	952-448-3303
Fax Number	:	952-448-4409

Provider Business Practice Location Address
First Line	:	822 YELLOW BRICK RD
Second Line	:
City	:	CHASKA
State	:	MN
Zip	:	55318-2152
Country	:	US
Telephone Number	:	952-448-3303
Fax Number	:	952-448-4409

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2005
Last Update Date	:	07/08/2007

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