Provider Demographics
NPI:1013005321
Name:LARSON, PAUL S (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:S
Last Name:LARSON
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:PO BOX 245070
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85724-5070
Mailing Address - Country:US
Mailing Address - Phone:520-626-4936
Mailing Address - Fax:520-626-8313
Practice Address - Street 1:1501 N CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85724-0350
Practice Address - Country:US
Practice Address - Phone:520-626-4936
Practice Address - Fax:520-626-8313
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2021-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76564174400000X
AZ63422207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ24752ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER #