Basic Information
| Provider Information | |||||||||
| NPI: | 1922147610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | CRAIG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 COCHRANE CIRCLE | ||||||||
| Address2: | DEPARTMENT OF THE ARMY USA MEDDAC EVANS ARMY COMMUNITY | ||||||||
| City: | FORT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195267649 | ||||||||
| FaxNumber: | 7195267019 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 COCHRANE CIRCLE | ||||||||
| Address2: | 1CU USA MEDDAC EVANS ARMY COMMUNITY HOSPITAL | ||||||||
| City: | FORT CARSON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809134604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195267020 | ||||||||
| FaxNumber: | 7195267635 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 164W00000X | 44156 | CO | Y | Nursing Service Providers | Licensed Practical Nurse | 164W00000X | 20219 | NE | N | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.