Provider Demographics
NPI:1659410983
Name:LARSEN, JAMIE P (PAC)
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:P
Last Name:LARSEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 E GERMANN RD
Mailing Address - Street 2:STE 2
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-1575
Mailing Address - Country:US
Mailing Address - Phone:480-878-5306
Mailing Address - Fax:
Practice Address - Street 1:2250 E GERMANN RD
Practice Address - Street 2:STE 2
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85286-1575
Practice Address - Country:US
Practice Address - Phone:480-878-5306
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT57597411206207VG0400X, 363AM0700X
AZ5177363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT553068427005Medicaid
UT553068427005Medicaid
AZZ197611Medicare PIN