Basic Information
| Provider Information | |||||||||
| NPI: | 1538103338 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | ELAINE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | GAYLORD FARMS RD. | ||||||||
| Address2: | PO BOX 400 | ||||||||
| City: | WALLINGFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032842800 | ||||||||
| FaxNumber: | 2036793598 | ||||||||
| Practice Location | |||||||||
| Address1: | GAYLORD FARMS RD. | ||||||||
| Address2: | |||||||||
| City: | WALLINGFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032842800 | ||||||||
| FaxNumber: | 2036793598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 000101 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.