Healthcare Provider Details

I. General information

NPI: 1568489458
Provider Name (Legal Business Name): LYNN ANN LARSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LYNN ANN DAMICO

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 DUNCAN RD
BUCKEYE WV
24924-9037
US

IV. Provider business mailing address

150 DUNCAN RD
BUCKEYE WV
24924-9037
US

V. Phone/Fax

Practice location:
  • Phone: 304-799-7400
  • Fax: 304-799-2276
Mailing address:
  • Phone: 304-799-7400
  • Fax: 304-799-2276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number01190
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4904
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: