1578536892 NPI number — GREGORY ALLEN LARSON FNP-BC

Table of content: GREGORY ALLEN LARSON FNP-BC (NPI 1578536892)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578536892 NPI number — GREGORY ALLEN LARSON FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARSON
Provider First Name:
GREGORY
Provider Middle Name:
ALLEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578536892
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 617
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOMERTON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85350-0617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-236-8001
Provider Business Mailing Address Fax Number:
928-722-6113

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1233 N MAIN ST
Provider Second Line Business Practice Location Address:
STE 1A
Provider Business Practice Location Address City Name:
SAN LUIS
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-550-5514
Provider Business Practice Location Address Fax Number:
928-722-6113
Provider Enumeration Date:
02/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  2973 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: AP2705 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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