Healthcare Provider Details

I. General information

NPI: 1518116516
Provider Name (Legal Business Name): EVA LARSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2008
Last Update Date: 09/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 WALTON WAY
AUGUSTA GA
30901-2612
US

IV. Provider business mailing address

5665 NEW NORTHSIDE DR NW SUITE 320
ATLANTA GA
30328-5831
US

V. Phone/Fax

Practice location:
  • Phone: 706-774-2176
  • Fax:
Mailing address:
  • Phone: 770-874-5400
  • Fax: 770-874-5469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number005093
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: