Provider Demographics
NPI:1467638031
Name:LARSON, KIRK RUSSEL (CRNA)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:RUSSEL
Last Name:LARSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 650865
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0865
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:
Practice Address - Street 1:6606 LBJ FWY STE 200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6524
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX661498367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX193018202OtherMEDICAID CSHCN
TX193018201Medicaid
TX193018204Medicaid
TX8332UGOtherBCBS TX
TX88744UOtherBCBS
TX88744UOtherBCBS
TX339044YK6UMedicare PIN