Provider Demographics
NPI:1942789318
Name:LARSON, MARK (FNP-C)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2373 AUGUSTA HWY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-2213
Mailing Address - Country:US
Mailing Address - Phone:803-951-0786
Mailing Address - Fax:
Practice Address - Street 1:2373 AUGUSTA HWY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-2213
Practice Address - Country:US
Practice Address - Phone:803-951-0786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19410363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily