Provider Demographics
NPI:1740659010
Name:LARSEN, BRENNEN (PA-C)
Entity type:Individual
Prefix:
First Name:BRENNEN
Middle Name:
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 WINN DR
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-5277
Mailing Address - Country:US
Mailing Address - Phone:208-881-5222
Mailing Address - Fax:887-441-4715
Practice Address - Street 1:21 WINN DR
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5277
Practice Address - Country:US
Practice Address - Phone:208-881-5222
Practice Address - Fax:877-441-4715
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-17
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6141363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant