Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 3500 | MN |
NPI | 1285642975 |
---|---|
Provider Name | Dr. John W Larson |
First Address | Elk River, MN 55330 |
Second Address | Woodbury, MN 55125-2282 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/08/2006 |
Last Update Date | 13/04/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
132MOHE | BLUE CROSS BLUE SHIELD (01) | MN |