Provider Demographics
NPI:1033114954
Name:WITHAM, LARRY E (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:E
Last Name:WITHAM
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
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Mailing Address - Street 1:MADIGAN ARMY MEDICAL CTR
Mailing Address - Street 2:9040A REID STREET
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431-1100
Mailing Address - Country:US
Mailing Address - Phone:541-561-1420
Mailing Address - Fax:
Practice Address - Street 1:MADIGAN ARMY MEDICAL CTR
Practice Address - Street 2:9040A REID STREET
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-1100
Practice Address - Country:US
Practice Address - Phone:541-922-3104
Practice Address - Fax:541-922-2951
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2013-05-16
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Provider Licenses
StateLicense IDTaxonomies
ORPA00965363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical