MEDICARE: CAROL N LARSEN PA

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	0253	SD

General Provider Information

NPI Number	:	1518980572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROL N LARSEN PA

Provider Business Mailing Address
First Line	:	4405 E 26TH ST
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57103-4136
Country	:	US
Telephone Number	:	605-332-2883
Fax Number	:	605-332-9101

Provider Business Practice Location Address
First Line	:	4405 E 26TH ST
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57103-4136
Country	:	US
Telephone Number	:	605-332-2883
Fax Number	:	605-332-9101

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

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	05/09/2008

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Directions to “ CAROL N LARSEN PA” Practice Location

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