| NPI | 1043645690 |
|---|---|
| Former Name | CARLY NICOLE LARSON |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: MN 11656) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: IL 085004730) |
| Enumeration Date | 2013-09-13 |
| Last Update Date | 2017-01-27 |