Provider Demographics
NPI:1568489458
Name:LARSON, LYNN ANN (PA)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:ANN
Last Name:LARSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:ANN
Other - Last Name:DAMICO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:150 DUNCAN RD
Mailing Address - Street 2:
Mailing Address - City:BUCKEYE
Mailing Address - State:WV
Mailing Address - Zip Code:24924-9037
Mailing Address - Country:US
Mailing Address - Phone:304-799-7400
Mailing Address - Fax:304-799-2276
Practice Address - Street 1:150 DUNCAN RD
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:WV
Practice Address - Zip Code:24924-9037
Practice Address - Country:US
Practice Address - Phone:304-799-7400
Practice Address - Fax:304-799-2276
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01190363A00000X
AZ4904363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S59797Medicare UPIN