Healthcare Provider Details

I. General information

NPI: 1003058504
Provider Name (Legal Business Name): MR. PAUL R LARSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2009
Last Update Date: 03/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 COLLEGE AVE
SANTA ROSA CA
95401-5117
US

IV. Provider business mailing address

327 COLLEGE AVE.
SANTA ROSA CA
95401
US

V. Phone/Fax

Practice location:
  • Phone: 707-568-2800
  • Fax: 707-568-2804
Mailing address:
  • Phone: 707-568-2800
  • Fax: 707-568-2804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: