Provider Demographics
NPI:1417285784
Name:LARSON, AMY ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:LARSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:130 HOSPITAL RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PRINCE FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:20678-4015
Mailing Address - Country:US
Mailing Address - Phone:410-535-1108
Mailing Address - Fax:410-535-4088
Practice Address - Street 1:130 HOSPITAL RD
Practice Address - Street 2:SUITE 101
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-4015
Practice Address - Country:US
Practice Address - Phone:410-535-1108
Practice Address - Fax:410-535-4088
Is Sole Proprietor?:No
Enumeration Date:2009-11-25
Last Update Date:2018-03-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDC0004119363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD198115Medicare PIN