Healthcare Provider Details

I. General information

NPI: 1730563172
Provider Name (Legal Business Name): JOSHUA LARSON FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9640 MENAUL BLVD NE
ALBUQUERQUE NM
87112-2217
US

IV. Provider business mailing address

6004 ESTRELLITA DEL NORTE RD NE
ALBUQUERQUE NM
87111-1365
US

V. Phone/Fax

Practice location:
  • Phone: 505-294-4167
  • Fax:
Mailing address:
  • Phone: 505-250-0874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-02713
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: