Provider Demographics
NPI:1740289511
Name:LARSEN, RENEE L (PA)
Entity type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:L
Last Name:LARSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:RENEE
Other - Middle Name:L
Other - Last Name:GREGOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1962 CHARLIE HALL BLVD.
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414
Mailing Address - Country:US
Mailing Address - Phone:843-722-8000
Mailing Address - Fax:843-723-7850
Practice Address - Street 1:1962 CHARLIE HALL BLVD.
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414
Practice Address - Country:US
Practice Address - Phone:843-722-8000
Practice Address - Fax:843-723-7850
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA817363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0092PAMedicaid
SCP64692Medicare UPIN
SC0092PAMedicaid