Provider Demographics
NPI:1528049467
Name:LARSON, HEIDI C (PA)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:C
Last Name:LARSON
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 1:2 W 42ND ST
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-0617
Mailing Address - Country:US
Mailing Address - Phone:308-630-1811
Mailing Address - Fax:
Practice Address - Street 1:2 W 42ND ST
Practice Address - Street 2:SUITE 1200
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-0617
Practice Address - Country:US
Practice Address - Phone:308-630-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE782363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE098637077OtherMEDICARE
NE36331415914Medicaid