Healthcare Provider Details

I. General information

NPI: 1932087665
Provider Name (Legal Business Name): BEAU LARSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W BROADWAY ST STE 320
MISSOULA MT
59802-4003
US

IV. Provider business mailing address

PO BOX 31001
PASADENA CA
91110-4110
US

V. Phone/Fax

Practice location:
  • Phone: 406-329-5615
  • Fax:
Mailing address:
  • Phone: 406-329-5615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMED-PAC-LIC-164422
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: