Basic Information
| Provider Information | |||||||||
| NPI: | 1003279456 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | CODY | ||||||||
| MiddleName: | BRAXTON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 263 18TH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941212314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4157044757 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 WHEELING AVE | ||||||||
| Address2: | |||||||||
| City: | GLEN DALE | ||||||||
| State: | WV | ||||||||
| PostalCode: | 260381660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048453211 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2016 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 25MA10897300 | NJ | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 29862 | WV | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 304201 | NY | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.