1366701955 NPI number — MRS. KATELYN ELIZABETH LARSEN PA-C

Table of content: DR. JONATHAN JAY SEIDLIN MD (NPI 1649273533)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366701955 NPI number — MRS. KATELYN ELIZABETH LARSEN PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARSEN
Provider First Name:
KATELYN
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CROUCH
Provider Other First Name:
KATELYN
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366701955
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/15/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
808 EAST PIERCE STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COUNCIL BLUFFS
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
51503-4652
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
712-396-4340
Provider Business Mailing Address Fax Number:
712-396-4180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
201 RIDGE ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
COUNCIL BLUFFS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
51503-4643
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
712-322-5899
Provider Business Practice Location Address Fax Number:
712-322-5730
Provider Enumeration Date:
05/16/2012

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: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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