Provider Demographics
NPI:1346369907
Name:LARSEN, PAUL
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:LARSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 ROUTE 37 W
Mailing Address - Street 2:DOVER MALL
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-6588
Mailing Address - Country:US
Mailing Address - Phone:732-341-7017
Mailing Address - Fax:732-341-0357
Practice Address - Street 1:2 ROUTE 37 W
Practice Address - Street 2:DOVER MALL
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08753-6588
Practice Address - Country:US
Practice Address - Phone:732-341-7017
Practice Address - Fax:732-341-0357
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MG00036200237700000X
FLAS2328237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3125009Medicaid