Provider Demographics
NPI:1043379829
Name:LARSON, KENNETH B (PA)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:B
Last Name:LARSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546-4081
Mailing Address - Country:US
Mailing Address - Phone:928-428-1947
Mailing Address - Fax:
Practice Address - Street 1:1600 S 20TH AVE
Practice Address - Street 2:
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-4011
Practice Address - Country:US
Practice Address - Phone:928-348-4021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1090363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ184841Medicaid
AZ184841Medicaid
AZS89621Medicare UPIN