MEDICARE: MS. TERI LEE LARSON-JOHNSON PA-C

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	9190	MN

General Provider Information

NPI Number	:	1891761664
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TERI LEE LARSON-JOHNSON PA-C

Provider Business Mailing Address
First Line	:	400 E 3RD ST
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55805-1951
Country	:	US
Telephone Number	:	218-786-8364
Fax Number	:

Provider Business Practice Location Address
First Line	:	420 E 1ST ST
Second Line	:
City	:	DULUTH
State	:	MN
Zip	:	55805-1901
Country	:	US
Telephone Number	:	218-786-8364
Fax Number	:	320-229-5160

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

Provider Enumeration Date	:	02/23/2006
Last Update Date	:	09/25/2023

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