Individual
STEPHEN LARSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
112 E 5TH AVE, ANTIGO, WI 54409-2710
(715) 623-2331
Mailing address
1752 EDGEWOOD RD, WINONA, MN 55987-2149
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
202157-30
WI
367500000X
Certified Registered Nurse Anesthetist
R-081276-4
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
136542800
—
MN
01
—
1882
IBAX
—
05
—
43293000
—
WI
01
—
52D0662095
CLIA
—
Enumeration date
05/26/2005
Last updated
04/16/2014
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