Provider Demographics
NPI:1487763314
Name:LARSON, PETER
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3608 KENNEDY ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-6416
Mailing Address - Country:US
Mailing Address - Phone:701-235-7860
Mailing Address - Fax:
Practice Address - Street 1:211 E MILL STREET
Practice Address - Street 2:
Practice Address - City:PELICAN RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56572-4234
Practice Address - Country:US
Practice Address - Phone:218-863-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6812OtherLICENSE #