Basic Information
| Provider Information | |||||||||
| NPI: | 1598146888 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LARSEN ANESTHESIA PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 20188 | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820037004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076380300 | ||||||||
| FaxNumber: | 3076380394 | ||||||||
| Practice Location | |||||||||
| Address1: | 3584 W 9000 S | ||||||||
| Address2: | |||||||||
| City: | WEST JORDAN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840885710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076380300 | ||||||||
| FaxNumber: | 3076380394 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2015 | ||||||||
| LastUpdateDate: | 06/12/2015 | ||||||||
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| AuthorizedOfficialLastName: | LARSEN | ||||||||
| AuthorizedOfficialFirstName: | NICHOLAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROVIDER/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3076380300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 76505701204 | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.