Provider Demographics
NPI:1922147610
Name:LARSON, MATTHEW CRAIG
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CRAIG
Last Name:LARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 COCHRANE CIRCLE
Mailing Address - Street 2:DEPARTMENT OF THE ARMY USA MEDDAC EVANS ARMY COMMUNITY
Mailing Address - City:FORT CARSON
Mailing Address - State:CO
Mailing Address - Zip Code:80913-4606
Mailing Address - Country:US
Mailing Address - Phone:719-526-7649
Mailing Address - Fax:719-526-7019
Practice Address - Street 1:1650 COCHRANE CIRCLE
Practice Address - Street 2:1CU USA MEDDAC EVANS ARMY COMMUNITY HOSPITAL
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913-4604
Practice Address - Country:US
Practice Address - Phone:719-526-7020
Practice Address - Fax:719-526-7635
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44156164W00000X
NE20219164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse