Provider Demographics
NPI:1124091749
Name:LARSON, PAUL (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:721 AMERICAN AVENUE SUITE 501
Mailing Address - Street 2:PHC BEHAVIORAL MEDICINE CENTER
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188
Mailing Address - Country:US
Mailing Address - Phone:262-928-2396
Mailing Address - Fax:262-544-1213
Practice Address - Street 1:721 AMERICAN AVENUE SUITE 501
Practice Address - Street 2:PHC BEHAVIORAL MEDICINE CENTER
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188
Practice Address - Country:US
Practice Address - Phone:262-928-2396
Practice Address - Fax:262-544-1213
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI390932084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34096900Medicaid
WI84767Medicare ID - Type Unspecified
WIH46225Medicare UPIN