Provider Demographics
NPI:1902321250
Name:LARSEN, NICHOLAS (CPNP-PC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:LARSEN
Suffix:
Gender:M
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 BROOKLINE PL STE 327
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02445-7238
Mailing Address - Country:US
Mailing Address - Phone:617-735-8585
Mailing Address - Fax:
Practice Address - Street 1:1 BROOKLINE PL STE 327
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02445-7238
Practice Address - Country:US
Practice Address - Phone:617-735-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2306931363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics