Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363L00000X | Nurse Practitioner | 510 | MN |
NPI | 1003883018 |
---|---|
Provider Name | Amy F Larson |
First Address | Bloomington, MN 55425-4516 |
Second Address | Saint Paul, MN 55130-2400 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/03/2006 |
Last Update Date | 05/03/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
135425600 | (05) | MN |
S58765 | (02) |