Healthcare Provider Details

I. General information

NPI: 1770926032
Provider Name (Legal Business Name): TIMOTHY PINETREE LARSEN DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 08/26/2020
Certification Date: 08/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3434 HANCOCK BRIDGE PKWY STE 309
NORTH FORT MYERS FL
33903-7099
US

IV. Provider business mailing address

2675 WINKLER AVE FL 2
FORT MYERS FL
33901-9342
US

V. Phone/Fax

Practice location:
  • Phone: 855-674-8800
  • Fax: 239-599-4126
Mailing address:
  • Phone: 877-856-3774
  • Fax: 239-599-2612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberCOA.14394-NP
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN3307382
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: