Healthcare Provider Details

I. General information

NPI: 1538128632
Provider Name (Legal Business Name): ERIC LARSEN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 01/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3307
US

IV. Provider business mailing address

P.O. BOX 759101
BALTIMORE MD
21275-0001
US

V. Phone/Fax

Practice location:
  • Phone: 703-776-3111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110001785
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: