Provider Demographics
NPI:1851365332
Name:WASHBURN, LARRY ALTON (PAC)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:ALTON
Last Name:WASHBURN
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 1:4374 NEW TOWN AVE
Mailing Address - Street 2:STE 100
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-2865
Mailing Address - Country:US
Mailing Address - Phone:757-252-1900
Mailing Address - Fax:757-259-1901
Practice Address - Street 1:5335 DISCOVERY PARK BLVD STE B
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2696
Practice Address - Country:US
Practice Address - Phone:757-253-0603
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840677363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P36874Medicare UPIN