Healthcare Provider Details

I. General information

NPI: 1437671237
Provider Name (Legal Business Name): JOHN DYLAN LARSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2017
Last Update Date: 07/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WOODRUFF CIR NE
ATLANTA GA
30322-1020
US

IV. Provider business mailing address

550 JOHN WESLEY DOBBS AVE NE APT B
ATLANTA GA
30312-1700
US

V. Phone/Fax

Practice location:
  • Phone: 140-472-7845
  • Fax: 404-727-8454
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: