Provider Demographics
NPI:1750300216
Name:LARSEN, RYAN L (PA-C)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:L
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2826 HARRIS ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-4809
Mailing Address - Country:US
Mailing Address - Phone:707-443-8066
Mailing Address - Fax:707-268-3250
Practice Address - Street 1:2826 HARRIS ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95503-4809
Practice Address - Country:US
Practice Address - Phone:707-443-8066
Practice Address - Fax:707-268-3250
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17509363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA175090Medicaid
970003244OtherRAILROAD MEDICARE
970003244OtherRAILROAD MEDICARE
CA0PA175090Medicaid