Provider Demographics
NPI:1649894403
Name:LARCO, KATHLYN TATIANA (PA-C)
Entity type:Individual
Prefix:
First Name:KATHLYN
Middle Name:TATIANA
Last Name:LARCO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHLYN
Other - Middle Name:TATIANA
Other - Last Name:LARCO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:26520 CACTUS AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-3927
Mailing Address - Country:US
Mailing Address - Phone:951-486-4000
Mailing Address - Fax:
Practice Address - Street 1:26520 CACTUS AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-3927
Practice Address - Country:US
Practice Address - Phone:951-486-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-07
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA59086207T00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty