Provider Demographics
NPI:1669920179
Name:LARSEN, TORY LEIF (APRN, NP)
Entity type:Individual
Prefix:MR
First Name:TORY
Middle Name:LEIF
Last Name:LARSEN
Suffix:
Gender:M
Credentials:APRN, NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:872 MASS AVE
Mailing Address - Street 2:APT 503
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3073
Mailing Address - Country:US
Mailing Address - Phone:973-919-4816
Mailing Address - Fax:
Practice Address - Street 1:872 MASS AVE
Practice Address - Street 2:APT 503
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3073
Practice Address - Country:US
Practice Address - Phone:973-919-4816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2308024363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110122144AMedicaid