Healthcare Provider Details

I. General information

NPI: 1528882834
Provider Name (Legal Business Name): JEFFERY LARSEN AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2024
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15816 N PENNSYLVANIA AVE STE 2
EDMOND OK
73013-7334
US

IV. Provider business mailing address

15816 N PENNSYLVANIA AVE STE 2
EDMOND OK
73013-7334
US

V. Phone/Fax

Practice location:
  • Phone: 405-755-6557
  • Fax: 405-513-6612
Mailing address:
  • Phone: 405-755-6557
  • Fax: 405-513-6612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number6352
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: