Provider Demographics
NPI:1316991086
Name:LARSEN, JILL KATHERINE (PA)
Entity type:Individual
Prefix:MRS
First Name:JILL
Middle Name:KATHERINE
Last Name:LARSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CROSBY
Mailing Address - State:MN
Mailing Address - Zip Code:56441-1645
Mailing Address - Country:US
Mailing Address - Phone:218-546-7000
Mailing Address - Fax:218-546-4400
Practice Address - Street 1:320 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CROSBY
Practice Address - State:MN
Practice Address - Zip Code:56441-1645
Practice Address - Country:US
Practice Address - Phone:218-546-7000
Practice Address - Fax:218-546-4400
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9975363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01-20460OtherMEDICA HILLMAN CLINIC
MN132635OtherUCARE
MNNA9091043681OtherPREFERRED ONE
MN430L3LAOtherBLUE CROSS CLINICS
MN01-20461OtherMEDICA ISLE CLINIC
MN01-20459OtherMEDICA ONAMIA CLINIC
MNHP50104OtherHEALTH PARTNERS
MN911435100Medicaid
MNHP50104OtherHEALTH PARTNERS
MN970002152Medicare Oscar/Certification
MN970002154Medicare ID - Type UnspecifiedISLE CLINIC
MN970002155Medicare ID - Type UnspecifiedONAMIA CLINIC