Provider Demographics
NPI:1245671379
Name:LARSEN, TUCKER LLOYD (PA-C)
Entity type:Individual
Prefix:
First Name:TUCKER
Middle Name:LLOYD
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 388
Mailing Address - Street 2:
Mailing Address - City:PLUMMER
Mailing Address - State:ID
Mailing Address - Zip Code:83851-0388
Mailing Address - Country:US
Mailing Address - Phone:208-686-1931
Mailing Address - Fax:208-686-0242
Practice Address - Street 1:427 N 12TH ST.
Practice Address - Street 2:
Practice Address - City:PLUMMER
Practice Address - State:ID
Practice Address - Zip Code:83851
Practice Address - Country:US
Practice Address - Phone:208-686-1931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
IDPA-1457363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program