Provider Demographics
NPI:1891502829
Name:LARSON, REAGAN
Entity type:Individual
Prefix:
First Name:REAGAN
Middle Name:
Last Name:LARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1408 NW SANTA FE LN APT 103
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-7728
Mailing Address - Country:US
Mailing Address - Phone:605-430-0732
Mailing Address - Fax:
Practice Address - Street 1:2321 NW SCHOLD PL
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-9504
Practice Address - Country:US
Practice Address - Phone:360-698-3930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant