Healthcare Provider Details

I. General information

NPI: 1831496496
Provider Name (Legal Business Name): CODY LARSON PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2011
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ANSBACH ARMY HEALTH CLINIC BLDG 8156 COMANCHE BLVD
APO AE
09250
US

IV. Provider business mailing address

92-104 WAIALII PL APT O-1021
KAPOLEI HI
96707-4425
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-3601
  • Fax:
Mailing address:
  • Phone: 808-354-8185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: