Healthcare Provider Details

I. General information

NPI: 1174770440
Provider Name (Legal Business Name): WESLEY REED LARSEN APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 05/26/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3550 N UNIVERSITY AVE STE 250
PROVO UT
84604-6695
US

IV. Provider business mailing address

1055 N 300 W STE 400
PROVO UT
84604-3359
US

V. Phone/Fax

Practice location:
  • Phone: 801-374-9625
  • Fax: 801-374-9690
Mailing address:
  • Phone: 801-357-7404
  • Fax: 801-357-7587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5121976-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: