Provider Demographics
NPI:1952362956
Name:LARSON, RUTH S (NP)
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:S
Last Name:LARSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:908 NIAGARA FALLS BLVD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-2019
Mailing Address - Country:US
Mailing Address - Phone:716-692-3302
Mailing Address - Fax:716-692-4342
Practice Address - Street 1:620 10TH ST
Practice Address - Street 2:STE. 703
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14301-1841
Practice Address - Country:US
Practice Address - Phone:716-278-0150
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYF303989363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02635147Medicaid
NY02635147Medicaid
NYQ39573Medicare UPIN