Provider Demographics
NPI:1205544871
Name:BOUSQUET, LARRY LEE II (FNP)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:LEE
Last Name:BOUSQUET
Suffix:II
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 E JOY LN
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-8807
Mailing Address - Country:US
Mailing Address - Phone:928-768-9496
Mailing Address - Fax:
Practice Address - Street 1:1611 E JOY LN # 1
Practice Address - Street 2:
Practice Address - City:FORT MOHAVE
Practice Address - State:AZ
Practice Address - Zip Code:86426-8807
Practice Address - Country:US
Practice Address - Phone:928-768-9496
Practice Address - Fax:928-768-1943
Is Sole Proprietor?:No
Enumeration Date:2022-11-11
Last Update Date:2022-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ283825363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner