Provider Demographics
NPI:1265656144
Name:LARSEN, KRISTIAN J (PA)
Entity Type:Individual
Prefix:
First Name:KRISTIAN
Middle Name:J
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16301 BADEN NAYLOR RD
Mailing Address - Street 2:
Mailing Address - City:BRANDYWINE
Mailing Address - State:MD
Mailing Address - Zip Code:20613-8510
Mailing Address - Country:US
Mailing Address - Phone:301-579-6078
Mailing Address - Fax:
Practice Address - Street 1:2855 CRAIN HWY
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20601-2840
Practice Address - Country:US
Practice Address - Phone:240-427-1926
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC01347363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD006532G47Medicare ID - Type Unspecified