Healthcare Provider Details

I. General information

NPI: 1578536892
Provider Name (Legal Business Name): GREGORY ALLEN LARSON FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 04/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1233 N MAIN ST STE 1A
SAN LUIS AZ
85349
US

IV. Provider business mailing address

PO BOX 617
SOMERTON AZ
85350-0617
US

V. Phone/Fax

Practice location:
  • Phone: 928-550-5514
  • Fax: 928-722-6113
Mailing address:
  • Phone: 928-236-8001
  • Fax: 928-722-6113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2973
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP2705
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: