MEDICARE: PETER LARSON

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	225100000X	Physical Therapist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6812	OTHER	MN	LICENSE #

General Provider Information

NPI Number	:	1487763314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETER LARSON

Provider Business Mailing Address
First Line	:	3608 KENNEDY ST S
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58104-6416
Country	:	US
Telephone Number	:	701-235-7860
Fax Number	:

Provider Business Practice Location Address
First Line	:	211 E MILL STREET
Second Line	:
City	:	PELICAN RAPIDS
State	:	MN
Zip	:	56572-4234
Country	:	US
Telephone Number	:	218-863-1140
Fax Number	:

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	10/14/2007

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Directions to “ PETER LARSON ” Practice Location

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