Provider Demographics
NPI:1093087306
Name:LARRY, JAMON (PA-C)
Entity Type:Individual
Prefix:
First Name:JAMON
Middle Name:
Last Name:LARRY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7677 OAKPORT ST FL 12
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94621-1929
Mailing Address - Country:US
Mailing Address - Phone:510-895-4225
Mailing Address - Fax:510-379-7440
Practice Address - Street 1:3600 BROADWAY
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5730
Practice Address - Country:US
Practice Address - Phone:510-752-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-01
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56576363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant