Healthcare Provider Details

I. General information

NPI: 1821680471
Provider Name (Legal Business Name): LARSON PLASTIC SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2021
Last Update Date: 02/05/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7005 N ORACLE RD
TUCSON AZ
85704-4329
US

IV. Provider business mailing address

7005 N ORACLE RD
TUCSON AZ
85704-4329
US

V. Phone/Fax

Practice location:
  • Phone: 520-771-0177
  • Fax: 520-300-7316
Mailing address:
  • Phone: 520-771-0177
  • Fax: 520-300-7316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ETHAN ERIC LARSON
Title or Position: CMO, CEO
Credential: MD
Phone: 520-771-0177