Provider Demographics
NPI:1154724052
Name:LARSON, BRETT (PA-C)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 MONARCH BAY PLZ # 122
Mailing Address - Street 2:
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-3424
Mailing Address - Country:US
Mailing Address - Phone:949-350-7508
Mailing Address - Fax:
Practice Address - Street 1:14 MONARCH BAY PLZ # 122
Practice Address - Street 2:
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-3424
Practice Address - Country:US
Practice Address - Phone:949-350-7508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51996207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine