Provider Demographics
NPI:1255569794
Name:LARSEN, MATTHEW ANTHONY (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ANTHONY
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 1:261 N MAIN
Mailing Address - Street 2:PO BOX 221 K
Mailing Address - City:CEDAR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49319-8041
Mailing Address - Country:US
Mailing Address - Phone:616-696-2020
Mailing Address - Fax:616-696-4860
Practice Address - Street 1:261 N MAIN
Practice Address - Street 2:
Practice Address - City:CEDAR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49319-8041
Practice Address - Country:US
Practice Address - Phone:616-696-2020
Practice Address - Fax:616-696-4860
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005508363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant