Provider Demographics
NPI:1861672909
Name:LARSEN, JILL R (PA-C)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:R
Last Name:LARSEN
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 1:11 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-5709
Mailing Address - Country:US
Mailing Address - Phone:228-872-2403
Mailing Address - Fax:228-875-7584
Practice Address - Street 1:11 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-5709
Practice Address - Country:US
Practice Address - Phone:228-872-2403
Practice Address - Fax:228-875-7584
Is Sole Proprietor?:No
Enumeration Date:2007-11-06
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00111363AS0400X
ALTA1635363AS0400X
MSPA00111363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical