Provider Demographics
NPI:1124409099
Name:LARSEN, WILLIAM (FNP)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:
Last Name:LARSEN
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 HANSHAW RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1549
Mailing Address - Country:US
Mailing Address - Phone:607-339-0670
Mailing Address - Fax:607-319-5524
Practice Address - Street 1:905 HANSHAW RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1549
Practice Address - Country:US
Practice Address - Phone:607-339-0670
Practice Address - Fax:607-319-5524
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY339752363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2734852OtherMEDICAID GROUP
NY1088OtherTOTAL CARE GROUP
NY04173960Medicaid
NY1088OtherTOTAL CARE GROUP
NYJ400229857Medicare PIN