Provider Demographics
NPI:1629134960
Name:LARSON, PAUL ROBERT (NP)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ROBERT
Last Name:LARSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 N CHELAN AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2028
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 HIGHLINE DR
Practice Address - Street 2:
Practice Address - City:EAST WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98802-5341
Practice Address - Country:US
Practice Address - Phone:509-884-0641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1340646363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1629134960Medicaid
WA316364OtherL&I
WA1629134960Medicaid