MEDICARE: ZACHARY JAMES LARSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1164258976
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ZACHARY JAMES LARSON

Provider Business Mailing Address
First Line	:	11168 ANTONINE WALL CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89141-4338
Country	:	US
Telephone Number	:	801-243-2267
Fax Number	:

Provider Business Practice Location Address
First Line	:	11168 ANTONINE WALL CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89141-4338
Country	:	US
Telephone Number	:	801-243-2267
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2024
Last Update Date	:	09/09/2024

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