Provider Demographics
NPI:1679553937
Name:LARSON, JEFFREY R (CRNP)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:R
Last Name:LARSON
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:717 STATE ST
Mailing Address - Street 2:SUITE 16, LL
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16501-1341
Mailing Address - Country:US
Mailing Address - Phone:814-877-7100
Mailing Address - Fax:814-877-2939
Practice Address - Street 1:201 STATE ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16550-0002
Practice Address - Country:US
Practice Address - Phone:814-877-6139
Practice Address - Fax:814-877-6093
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP007048363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02799186OtherNY MEDICAL ASSISTANC
WV3000584OtherWEST VIRGINIA WORK COMP
PA066897E7CMedicare PIN
WV3000584OtherWEST VIRGINIA WORK COMP