Provider Demographics
NPI:1427041433
Name:LARSON, CAROL JEAN (MD)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:JEAN
Last Name:LARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 RICE ST
Mailing Address - Street 2:#160
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55113-3741
Mailing Address - Country:US
Mailing Address - Phone:651-483-2033
Mailing Address - Fax:651-483-1734
Practice Address - Street 1:800 E 28TH ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-3723
Practice Address - Country:US
Practice Address - Phone:612-863-4670
Practice Address - Fax:612-863-8375
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2011-02-16
Deactivation Date:2010-12-17
Deactivation Code:
Reactivation Date:2011-02-16
Provider Licenses
StateLicense IDTaxonomies
MN30137207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology