Healthcare Provider Details

I. General information

NPI: 1558101527
Provider Name (Legal Business Name): JASON BRADLEY LARSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2024
Last Update Date: 05/28/2024
Certification Date: 05/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 N CAMPBELL AVE
TUCSON AZ
85719-4330
US

IV. Provider business mailing address

1501 N CAMPBELL AVE STE 4401
TUCSON AZ
85724-5114
US

V. Phone/Fax

Practice location:
  • Phone: 520-626-7221
  • Fax: 520-626-6943
Mailing address:
  • Phone: 520-626-7221
  • Fax: 520-626-6943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberR4238
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: