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NPI Code Detail

MEDICARE: MRS. SHELLY LYNN LARSON PA-C

MEDICARE: MRS. SHELLY LYNN LARSON 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
1363A00000XPhysician Assistant9815MN

General Provider Information

NPI Number : 1982690145
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. SHELLY LYNN LARSON PA-C
Provider Business Mailing Address
First Line : 4480 CENTERVILLE RD
Second Line :
City : SAINT PAUL
State : MN
Zip : 55127-3674
Country : US
Telephone Number : 651-484-2724
Fax Number : 651-484-2723
Provider Business Practice Location Address
First Line : 4480 CENTERVILLE RD
Second Line :
City : SAINT PAUL
State : MN
Zip : 55127-3674
Country : US
Telephone Number : 651-484-2724
Fax Number : 651-484-2723
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/23/2005
Last Update Date : 05/14/2012

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