MEDICARE: MARIANNE LARSEN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	0003034	FL

General Provider Information

NPI Number	:	1043350093
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIANNE LARSEN PA-C

Provider Business Mailing Address
First Line	:	1007 PINE AVE SW
Second Line	:
City	:	LIVE OAK
State	:	FL
Zip	:	32064-4021
Country	:	US
Telephone Number	:	386-362-7822
Fax Number	:

Provider Business Practice Location Address
First Line	:	4225 NW AMERICAN LN
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32055-4881
Country	:	US
Telephone Number	:	386-758-6141
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	07/08/2007

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Directions to “ MARIANNE LARSEN PA-C” Practice Location

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