Provider Demographics
NPI:1770926032
Name:LARSEN, TIMOTHY PINETREE (DNP)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:PINETREE
Last Name:LARSEN
Suffix:
Gender:M
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2612
Practice Address - Street 1:3434 HANCOCK BRIDGE PKWY STE 309
Practice Address - Street 2:
Practice Address - City:NORTH FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33903-7099
Practice Address - Country:US
Practice Address - Phone:855-674-8800
Practice Address - Fax:239-599-4126
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.14394-NP363LA2200X
FLAPRN3307382363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104893800Medicaid
FLYC9Q0OtherBCBS
FLLD356OtherMEDICARE