Healthcare Provider Details

I. General information

NPI: 1144700782
Provider Name (Legal Business Name): BRAD DAVID LARSEN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: BRADLEY DAVID LARSEN PA-C

II. Dates (important events)

Enumeration Date: 08/14/2018
Last Update Date: 08/17/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31ST MEDICAL GROUP UNIT 6180
APO AE
09604
US

IV. Provider business mailing address

31 MEDICAL GROUP UNIT 6180
APO AE
09604
US

V. Phone/Fax

Practice location:
  • Phone: 314-632-5105
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1161415
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1161415
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: