Basic Information
| Provider Information | |||||||||
| NPI: | 1255302352 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | SETH | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1985 TATE BLVD SE | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | HICKERY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286021498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283285500 | ||||||||
| FaxNumber: | 8284852517 | ||||||||
| Practice Location | |||||||||
| Address1: | 10474 W THUNDERBIRD BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SUN CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853513015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239723800 | ||||||||
| FaxNumber: | 6239721089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2006 | ||||||||
| LastUpdateDate: | 02/08/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 2006 01761 | NC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 890241P | 05 | NC | MEDICAID |