Provider Demographics
NPI:1013386960
Name:LARSON, AMANDA TIPTON (CRNA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:TIPTON
Last Name:LARSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:AMANDA
Other - Last Name:TIPTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-2286
Mailing Address - Fax:
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4210
Practice Address - Country:US
Practice Address - Phone:864-522-2286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23844367500000X
MO2008011702367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered