Provider Demographics
NPI:1760528855
Name:LARSEN, JAMES C (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:C
Last Name:LARSEN
Suffix:
Gender:M
Credentials:MD
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 517
Mailing Address - Street 2:
Mailing Address - City:SUNDANCE
Mailing Address - State:WY
Mailing Address - Zip Code:82729-0517
Mailing Address - Country:US
Mailing Address - Phone:307-283-3501
Mailing Address - Fax:307-283-2489
Practice Address - Street 1:713 OAK ST.
Practice Address - Street 2:
Practice Address - City:SUNDANCE
Practice Address - State:WY
Practice Address - Zip Code:82729-0517
Practice Address - Country:US
Practice Address - Phone:307-283-3501
Practice Address - Fax:307-283-2255
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2018-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY4487A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT810542541OtherCOMMERCIAL
MTB43235Medicare UPIN
MT4457950001Medicare NSC
MT011002373Medicare PIN