Provider Demographics
NPI:1215523337
Name:LARSEN, BRANDON LEON (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:LEON
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:891 TIE BREAKER DR
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-4554
Mailing Address - Country:US
Mailing Address - Phone:208-569-8676
Mailing Address - Fax:
Practice Address - Street 1:1301 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6273
Practice Address - Country:US
Practice Address - Phone:208-991-4296
Practice Address - Fax:208-656-2846
Is Sole Proprietor?:No
Enumeration Date:2020-12-13
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1985363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical