Provider Demographics
NPI:1821284654
Name:LARSEN, ANGIE R (MD)
Entity Type:Individual
Prefix:DR
First Name:ANGIE
Middle Name:R
Last Name:LARSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:ANGIE
Other - Middle Name:RENEE
Other - Last Name:LARSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3024 BUSINESS PARK CIR
Mailing Address - Street 2:
Mailing Address - City:GOODLETTSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37072-3132
Mailing Address - Country:US
Mailing Address - Phone:615-239-2018
Mailing Address - Fax:
Practice Address - Street 1:300 STONECREST BLVD
Practice Address - Street 2:SUITE 330
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-5688
Practice Address - Country:US
Practice Address - Phone:615-331-8150
Practice Address - Fax:615-331-8151
Is Sole Proprietor?:No
Enumeration Date:2007-09-14
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30449208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I994466Medicare PIN
TNG88297Medicare UPIN