Provider Demographics
NPI:1689166266
Name:LARSEN, MARK WAYNE (MSN-E, FNP-C, CEN)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:WAYNE
Last Name:LARSEN
Suffix:
Gender:M
Credentials:MSN-E, FNP-C, CEN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 W 7615 S
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:UT
Mailing Address - Zip Code:84340-9525
Mailing Address - Country:US
Mailing Address - Phone:435-979-7546
Mailing Address - Fax:
Practice Address - Street 1:901 ADAMS ST
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:WY
Practice Address - Zip Code:83110-9621
Practice Address - Country:US
Practice Address - Phone:885-885-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1758.1758363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily