1912954728 NPI number — NATHANAEL M LARSEN PH.D.

Table of content: NATHANAEL M LARSEN PH.D. (NPI 1912954728)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912954728 NPI number — NATHANAEL M LARSEN PH.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARSEN
Provider First Name:
NATHANAEL
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PH.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912954728
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23355 OAKVIEW HEIGHTS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FERGUS FALLS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56537-8163
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
126 E ALCOTT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FERGUS FALLS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56537-2903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-736-6987
Provider Business Practice Location Address Fax Number:
218-736-6980
Provider Enumeration Date:
05/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  LP2878 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: HP23070 . This is a "HEALTHPARTNER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1010714 . This is a "PREFERREDONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 62-20513 . This is a "UNITED BEHAVIOR HEALTH" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 57399LA . This is a "MN BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 116689 . This is a "UCARE MINNESOTA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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