Provider Demographics
NPI:1235182312
Name:LARSEN, RICHARD E (PA C)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:E
Last Name:LARSEN
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 1:5290 MCNUTT ROAD
Mailing Address - Street 2:PO BOX 1590
Mailing Address - City:SANTA TERESA
Mailing Address - State:NM
Mailing Address - Zip Code:88008-1590
Mailing Address - Country:US
Mailing Address - Phone:505-589-1144
Mailing Address - Fax:505-589-2008
Practice Address - Street 1:5290 MCNUTT ROAD
Practice Address - Street 2:
Practice Address - City:SANTA TERESA
Practice Address - State:NM
Practice Address - Zip Code:88008-1590
Practice Address - Country:US
Practice Address - Phone:505-589-1144
Practice Address - Fax:505-589-2008
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMN99PA22363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00120OtherBCBS OF NM
P33021Medicare UPIN