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

Table of content: MRS. KATELYN ELIZABETH LARSEN PA-C (NPI 1366701955)

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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