Provider Demographics
NPI:1356354666
Name:LARSON, JOHN R (PA)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:LARSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1945 ROUTE 33
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07754
Mailing Address - Country:US
Mailing Address - Phone:732-776-4292
Mailing Address - Fax:732-776-2428
Practice Address - Street 1:1945 STATE ROUTE 33
Practice Address - Street 2:
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-4859
Practice Address - Country:US
Practice Address - Phone:732-776-4292
Practice Address - Fax:732-776-2428
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC1053363A00000X
NJ25MP000162363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJS67829Medicare UPIN
NJ021753UVPMedicare PIN