Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207PE0004X | Emergency Medical Services | 36489 | MN |
NPI | 1033147251 |
---|---|
Provider Name | Denise Marie Larson |
First Address | Mora, MN 55051-1899 |
Second Address | Mora, MN 55051-1899 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/06/2006 |
Last Update Date | 22/04/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
302513600 | (05) | MN |
E25661 | (02) |