Provider Demographics
NPI:1992539803
Name:LARSON, ALYSIA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:ALYSIA
Middle Name:MARIE
Last Name:LARSON
Suffix:
Gender:F
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 1:7308 BRIDGEPORT WAY W STE 201
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-8000
Mailing Address - Country:US
Mailing Address - Phone:253-582-7257
Mailing Address - Fax:253-582-1617
Practice Address - Street 1:2727 HOLLYCROFT ST STE 410
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98335-1369
Practice Address - Country:US
Practice Address - Phone:253-358-4002
Practice Address - Fax:253-358-4015
Is Sole Proprietor?:No
Enumeration Date:2024-09-02
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61601163363AS0400X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2303843Medicaid