Healthcare Provider Details

I. General information

NPI: 1477171494
Provider Name (Legal Business Name): LARSON THOMAS VICKERY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2020
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3545 WHITEHALL PARK DR STE 300
CHARLOTTE NC
28273-4179
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 980-302-8850
  • Fax:
Mailing address:
  • Phone: 704-384-9414
  • Fax: 704-384-5735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-10264
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: