Provider Demographics
NPI:1821680471
Name:LARSON PLASTIC SURGERY, PLLC
Entity Type:Organization
Organization Name:LARSON PLASTIC SURGERY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CMO, CEO
Authorized Official - Prefix:
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-771-0177
Mailing Address - Street 1:7005 N ORACLE RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-4329
Mailing Address - Country:US
Mailing Address - Phone:520-771-0177
Mailing Address - Fax:520-300-7316
Practice Address - Street 1:7005 N ORACLE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-4329
Practice Address - Country:US
Practice Address - Phone:520-771-0177
Practice Address - Fax:520-300-7316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty