Provider Demographics
NPI:1730652280
Name:LARSON, BRANDY LEE (FNP)
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:LEE
Last Name:LARSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 POTOMAC WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4970
Mailing Address - Country:US
Mailing Address - Phone:208-557-2900
Mailing Address - Fax:208-557-2910
Practice Address - Street 1:808 PANCHERI DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3344
Practice Address - Country:US
Practice Address - Phone:208-557-2900
Practice Address - Fax:208-557-2910
Is Sole Proprietor?:No
Enumeration Date:2019-01-08
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID60357363L00000X
IDCNP60357207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1730652280Medicaid