Provider Demographics
NPI:1669481776
Name:LARSEN, JENNIFER (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:PA-C
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 1358
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67201-1358
Mailing Address - Country:US
Mailing Address - Phone:316-293-3429
Mailing Address - Fax:855-495-3229
Practice Address - Street 1:8533 E 32ND ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-2611
Practice Address - Country:US
Practice Address - Phone:316-293-2622
Practice Address - Fax:855-517-9494
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00679363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
S86535Medicare UPIN
KS9358OtherPHS
KS110238059Medicare Oscar/Certification
KS042678OtherBCBS
KS100345210EMedicaid
KS10034521ODMedicaid
KS110238059OtherMEDICARE, KANSAS
KS203457OtherHPK
KS042678Medicare ID - Type Unspecified