Provider Demographics
NPI:1902903784
Name:LACROSSE, LARRY E (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:E
Last Name:LACROSSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10625 W NORTH AVE
Mailing Address - Street 2:102
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2315
Mailing Address - Country:US
Mailing Address - Phone:414-877-5350
Mailing Address - Fax:414-877-5360
Practice Address - Street 1:10625 W NORTH AVE
Practice Address - Street 2:102
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-2315
Practice Address - Country:US
Practice Address - Phone:414-877-5350
Practice Address - Fax:414-877-5360
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76912207P00000X
WI30441207P00000X
HI10435207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31664300Medicaid
WI31664300Medicaid
WI0004Medicare PIN
WI000301473Medicare PIN
WI0005Medicare PIN