=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073599841
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARRY JAMES PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2005
-----------------------------------------------------
Last Update Date | 12/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 777 37TH ST SUITE B-107
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32960-4873
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-226-5026
-----------------------------------------------------
Fax | 772-226-7682
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 777 37TH STREET SUITE B-107
-----------------------------------------------------
City | VERO BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32960-7301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-226-5026
-----------------------------------------------------
Fax | 772-226-7682
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA9101301
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------