Provider Demographics
NPI:1942434998
Name:LARSON, CASEY BLAINE (APRN)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:BLAINE
Last Name:LARSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:CASEY
Other - Middle Name:BLAINE
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8801 W LINEBAUGH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-1848
Mailing Address - Country:US
Mailing Address - Phone:668-389-2727
Mailing Address - Fax:
Practice Address - Street 1:8801 W LINEBAUGH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-05
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9267893363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001083600Medicaid
FLP00927067OtherMEDICARE RAILROAD
FLBV511ZMedicare PIN