Provider Demographics
NPI:1710920970
Name:DEAN, LARRY W (CRNP)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:W
Last Name:DEAN
Suffix:
Gender:M
Credentials:CRNP
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 55310
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35255-5310
Mailing Address - Country:US
Mailing Address - Phone:205-731-9701
Mailing Address - Fax:
Practice Address - Street 1:619 19TH STREET SOUTH
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233
Practice Address - Country:US
Practice Address - Phone:205-934-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-040511363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051505099OtherBLUE CROSS
AL051551249Medicaid
AL500021681OtherRAILROAD MEDICARE
AL051505098OtherBLUE CROSS
AL891003450Medicaid
AL051505098OtherBLUE CROSS