Healthcare Provider Details

I. General information

NPI: 1679553937
Provider Name (Legal Business Name): JEFFREY R LARSON CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2006
Last Update Date: 05/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 STATE ST
ERIE PA
16550-0002
US

IV. Provider business mailing address

717 STATE ST SUITE 16, LL
ERIE PA
16501-1341
US

V. Phone/Fax

Practice location:
  • Phone: 814-877-6139
  • Fax: 814-877-6093
Mailing address:
  • Phone: 814-877-7100
  • Fax: 814-877-2939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP007048
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: