MEDICARE: PIERCE LARKE PA

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	363A00000X	Physician Assistant	10003928A	IN

General Provider Information

NPI Number	:	1407567647
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PIERCE LARKE PA

Provider Business Mailing Address
First Line	:	2932 W LUDWIG RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-1328
Country	:	US
Telephone Number	:	260-755-1304
Fax Number	:

Provider Business Practice Location Address
First Line	:	2932 W LUDWIG RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-1328
Country	:	US
Telephone Number	:	260-755-1304
Fax Number	:

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

Provider Enumeration Date	:	12/08/2022
Last Update Date	:	02/23/2026

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Directions to “ PIERCE LARKE PA” Practice Location

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