Basic Information
| Provider Information | |||||||||
| NPI: | 1144301458 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2A DOCTORS DR | ||||||||
| Address2: | |||||||||
| City: | OCEAN SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395645721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288721951 | ||||||||
| FaxNumber: | 2288759998 | ||||||||
| Practice Location | |||||||||
| Address1: | 2A DOCTORS DR | ||||||||
| Address2: | |||||||||
| City: | OCEAN SPRINGS | ||||||||
| State: | MS | ||||||||
| PostalCode: | 395645721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2288721951 | ||||||||
| FaxNumber: | 2288759998 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 05/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA-519 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 200067 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | PA00156 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 06105593 | 05 | MS | MEDICAID | 1371866 | 05 | LA | MEDICAID | 302I970729 | 01 | MS | MEDICARE | OTHER |