Provider Demographics
NPI:1336268572
Name:FOLLETT-LARSON, LAURA JANE (PA-C)
Entity type:Individual
Prefix:MISS
First Name:LAURA
Middle Name:JANE
Last Name:FOLLETT-LARSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:JANE
Other - Last Name:FOLLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4418 XERXES AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-1417
Mailing Address - Country:US
Mailing Address - Phone:612-998-9057
Mailing Address - Fax:
Practice Address - Street 1:5775 WAYZATA BLVD STE 255
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-1275
Practice Address - Country:US
Practice Address - Phone:952-525-4450
Practice Address - Fax:952-525-1560
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10230363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant