Provider Demographics
NPI:1578536892
Name:LARSON, GREGORY ALLEN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:ALLEN
Last Name:LARSON
Suffix:
Gender:M
Credentials:FNP-BC
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 617
Mailing Address - Street 2:
Mailing Address - City:SOMERTON
Mailing Address - State:AZ
Mailing Address - Zip Code:85350-0617
Mailing Address - Country:US
Mailing Address - Phone:928-236-8001
Mailing Address - Fax:928-722-6113
Practice Address - Street 1:1233 N MAIN ST
Practice Address - Street 2:STE 1A
Practice Address - City:SAN LUIS
Practice Address - State:AZ
Practice Address - Zip Code:85349
Practice Address - Country:US
Practice Address - Phone:928-550-5514
Practice Address - Fax:928-722-6113
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2973363LF0000X
AZAP2705363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN358653700Medicaid
MN500004597Medicare PIN
MN358653700Medicaid
500003022Medicare ID - Type Unspecified