Provider Demographics
NPI:1982868576
Name:LARSON, DIANA KAY (PAC)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:KAY
Last Name:LARSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:23110 ATLANTIC CIR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-5920
Mailing Address - Country:US
Mailing Address - Phone:951-924-9931
Mailing Address - Fax:951-243-8126
Practice Address - Street 1:23110 ATLANTIC CIR
Practice Address - Street 2:SUITE A
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-5920
Practice Address - Country:US
Practice Address - Phone:951-924-9931
Practice Address - Fax:951-243-8126
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-14
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17311363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant