Provider Demographics
NPI:1578879441
Name:LARSEN, GREG ERIC (APRN)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:ERIC
Last Name:LARSEN
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 S 1000 E
Mailing Address - Street 2:STE 103
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84790-5902
Mailing Address - Country:US
Mailing Address - Phone:435-652-1135
Mailing Address - Fax:435-652-1190
Practice Address - Street 1:624 S 1000 E
Practice Address - Street 2:STE 103
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-5902
Practice Address - Country:US
Practice Address - Phone:435-652-1135
Practice Address - Fax:435-652-1190
Is Sole Proprietor?:No
Enumeration Date:2010-08-29
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT354177-4405363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1578879441Medicaid