Basic Information
| Provider Information | |||||||||
| NPI: | 1578879441 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | GREG | ||||||||
| MiddleName: | ERIC | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 624 S 1000 E | ||||||||
| Address2: | STE 103 | ||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847905902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356521135 | ||||||||
| FaxNumber: | 4356521190 | ||||||||
| Practice Location | |||||||||
| Address1: | 624 S 1000 E | ||||||||
| Address2: | STE 103 | ||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847905902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356521135 | ||||||||
| FaxNumber: | 4356521190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2010 | ||||||||
| LastUpdateDate: | 03/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 354177-4405 | UT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 354177-4405 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1578879441 | 05 | UT | MEDICAID |