Provider Demographics
NPI:1124087622
Name:LARSON, ELISE CHRISTINE BRODIN (MD)
Entity type:Individual
Prefix:DR
First Name:ELISE
Middle Name:CHRISTINE BRODIN
Last Name:LARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ELISE
Other - Middle Name:CHRISTINE
Other - Last Name:BRODIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:323 WASHINGTON AVE N STE 200
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55401-2206
Mailing Address - Country:US
Mailing Address - Phone:952-698-9860
Mailing Address - Fax:
Practice Address - Street 1:5130 MAIN ST NE
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55421-1528
Practice Address - Country:US
Practice Address - Phone:612-216-1471
Practice Address - Fax:833-972-1587
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40650207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H29516Medicare UPIN
080012849Medicare ID - Type Unspecified