Provider Demographics
NPI:1245222181
Name:LARSEN, PHILIP J (DPM)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:J
Last Name:LARSEN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:10561 JEFFREYS ST
Mailing Address - Street 2:#110
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-4266
Mailing Address - Country:US
Mailing Address - Phone:702-456-3668
Mailing Address - Fax:702-456-6688
Practice Address - Street 1:10561 JEFFREYS ST
Practice Address - Street 2:110
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4179
Practice Address - Country:US
Practice Address - Phone:702-456-3668
Practice Address - Fax:702-456-6688
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV0005213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV38608Medicare PIN
NVU86391Medicare UPIN