Provider Demographics
NPI:1114336278
Name:LARSON, BROOKE LOU (PA-C)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:LOU
Last Name:LARSON
Suffix:
Gender:F
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 1:703 S BROOKSIDE CT
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-8157
Mailing Address - Country:US
Mailing Address - Phone:858-361-2837
Mailing Address - Fax:
Practice Address - Street 1:2630 E CITIZENS DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4797
Practice Address - Country:US
Practice Address - Phone:479-527-9966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-03
Last Update Date:2014-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant