Healthcare Provider Details

I. General information

NPI: 1477513562
Provider Name (Legal Business Name): DON K LARUE MPAS,APA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 HWY 89 NORTH
PRESCOTT AZ
86313
US

IV. Provider business mailing address

5231 N LONE DR
PRESCOTT VALLEY AZ
86314-4339
US

V. Phone/Fax

Practice location:
  • Phone: 800-949-1005
  • Fax: 928-776-6125
Mailing address:
  • Phone: 800-949-1005
  • Fax: 928-776-6125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number186
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: