Provider Demographics
NPI:1821158346
Name:LARSON, ANDREA (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
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 1:1047 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEST RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05777-9526
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 ALLEN ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4560
Practice Address - Country:US
Practice Address - Phone:802-775-7111
Practice Address - Fax:802-747-6260
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030490363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VTOVN0503Medicaid
VTOVN0503Medicaid
S75261Medicare UPIN