Provider Demographics
NPI:1306514252
Name:LARSON, MADELINE LORRAINE
Entity type:Individual
Prefix:
First Name:MADELINE
Middle Name:LORRAINE
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 1ST ST APT 7
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-1834
Mailing Address - Country:US
Mailing Address - Phone:715-225-4982
Mailing Address - Fax:
Practice Address - Street 1:10450 185TH ST W STE 100
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-6696
Practice Address - Country:US
Practice Address - Phone:612-509-6690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other