Healthcare Provider Details

I. General information

NPI: 1659410983
Provider Name (Legal Business Name): JAMIE P LARSEN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 E SOUTHERN AVE
MESA AZ
85204-5411
US

IV. Provider business mailing address

25 CROSSROADS DR STE 306
OWINGS MILLS MD
21117-5437
US

V. Phone/Fax

Practice location:
  • Phone: 480-834-4188
  • Fax:
Mailing address:
  • Phone: 602-222-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number57597411206
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5177
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number57597411206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: