Provider Demographics
NPI:1528296043
Name:LARSON, ANDREW JON (DO)
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:JON
Last Name:LARSON
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:9900 13TH AVENUE NORTH
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-5035
Mailing Address - Country:US
Mailing Address - Phone:763-525-0363
Mailing Address - Fax:763-525-0369
Practice Address - Street 1:9900 13TH AVENUE NORTH
Practice Address - Street 2:SUITE 2A
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-5035
Practice Address - Country:US
Practice Address - Phone:763-525-0363
Practice Address - Fax:763-525-0369
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2014-10-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN02003283A207ZD0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN02003283AOtherINDIANA PROFESSIONAL LICENSING AGENCY