Provider Demographics
NPI:1831496496
Name:LARSON, CODY (PAC)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92-104 WAIALII PL
Mailing Address - Street 2:APT O-1021
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-4425
Mailing Address - Country:US
Mailing Address - Phone:808-354-8185
Mailing Address - Fax:
Practice Address - Street 1:677 MCCORNACK RD
Practice Address - Street 2:
Practice Address - City:WAHIAWA
Practice Address - State:HI
Practice Address - Zip Code:96786
Practice Address - Country:US
Practice Address - Phone:808-354-8185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-17
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIVAD000Medicare UPIN