Provider Demographics
NPI:1689904492
Name:LARGEN, MICHIAL JAMES JR (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHIAL
Middle Name:JAMES
Last Name:LARGEN
Suffix:JR
Gender:M
Credentials:CRNA
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 10824
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35202-0824
Mailing Address - Country:US
Mailing Address - Phone:800-800-1617
Mailing Address - Fax:866-759-5426
Practice Address - Street 1:142 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-2922
Practice Address - Country:US
Practice Address - Phone:434-799-2375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-30
Last Update Date:2010-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001153799367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA022278N75Medicare PIN