Provider Demographics
NPI:1225419120
Name:LARSON, JAIMEE M (PA-C)
Entity Type:Individual
Prefix:
First Name:JAIMEE
Middle Name:M
Last Name:LARSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JAIMEE
Other - Middle Name:M
Other - Last Name:LOFQUIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:704 S WEBSTER AVE STE 501
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3528
Practice Address - Country:US
Practice Address - Phone:920-433-6050
Practice Address - Fax:920-433-6049
Is Sole Proprietor?:No
Enumeration Date:2015-06-16
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3545-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1116573OtherNCCPA
WIK400229353Medicare Oscar/Certification
WIK400228992Medicare Oscar/Certification