Provider Demographics
NPI:1952422586
Name:LARSON, NICOLE MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:LARSON
Suffix:
Gender:F
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 1:1 MELLON WAY
Mailing Address - Street 2:
Mailing Address - City:LATROBE
Mailing Address - State:PA
Mailing Address - Zip Code:15650-1197
Mailing Address - Country:US
Mailing Address - Phone:724-689-0520
Mailing Address - Fax:724-689-0522
Practice Address - Street 1:1 MELLON WAY
Practice Address - Street 2:
Practice Address - City:LATROBE
Practice Address - State:PA
Practice Address - Zip Code:15650-1197
Practice Address - Country:US
Practice Address - Phone:724-689-0520
Practice Address - Fax:724-689-0522
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA053443363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant