Provider Demographics
NPI:1659410983
Name:LARSEN, JAMIE P (PAC)
Entity type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:P
Last Name:LARSEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 CROSSROADS DR STE 306
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5437
Mailing Address - Country:US
Mailing Address - Phone:602-222-1900
Mailing Address - Fax:
Practice Address - Street 1:2530 E SOUTHERN AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-5411
Practice Address - Country:US
Practice Address - Phone:480-834-4188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT57597411206207VG0400X, 363AM0700X
AZ5177363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT553068427005Medicaid
AZ005752Medicaid
AZZ197611Medicare PIN