Provider Demographics
NPI:1639367337
Name:LARSEN, BRETT C (PA)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:C
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:210 W 300 N
Mailing Address - Street 2:75-3
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-2336
Mailing Address - Country:US
Mailing Address - Phone:435-722-3971
Mailing Address - Fax:435-722-9291
Practice Address - Street 1:210 W 300 N
Practice Address - Street 2:75-3
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-2336
Practice Address - Country:US
Practice Address - Phone:435-722-3971
Practice Address - Fax:435-722-9291
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT6704805-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant