Provider Demographics
NPI:1053332890
Name:LARSEN, ERIK A (PA)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:A
Last Name:LARSEN
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:PO BOX 60318
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0318
Mailing Address - Country:US
Mailing Address - Phone:703-383-6469
Mailing Address - Fax:703-385-0575
Practice Address - Street 1:1850 TOWN CENTER PARKWAY
Practice Address - Street 2:SUITE 400
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190
Practice Address - Country:US
Practice Address - Phone:703-810-5202
Practice Address - Fax:703-787-9664
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001633363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00071404OtherMEDICARE RAILROAD
001087C95Medicare PIN
538695Medicare PIN
P00071404OtherMEDICARE RAILROAD