MEDICARE: DR. ETHAN ERIK LARSON MD

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	208200000X	Plastic Surgery Physician	42811	AZ

General Provider Information

NPI Number	:	1871741124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ETHAN ERIK LARSON MD

Provider Business Mailing Address
First Line	:	7005 N ORACLE RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85704-4329
Country	:	US
Telephone Number	:	520-771-0177
Fax Number	:	520-300-7316

Provider Business Practice Location Address
First Line	:	7005 N ORACLE RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85704-4329
Country	:	US
Telephone Number	:	520-771-0177
Fax Number	:

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

Provider Enumeration Date	:	08/28/2008
Last Update Date	:	04/08/2021

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