Provider Demographics
NPI:1376656421
Name:LARSON, PAUL DANIEL (NP)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:DANIEL
Last Name:LARSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:ESSEX JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05452-4000
Mailing Address - Country:US
Mailing Address - Phone:802-777-6639
Mailing Address - Fax:
Practice Address - Street 1:1 WALLACE BASHAW WAY
Practice Address - Street 2:SUITE 2001
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950-3875
Practice Address - Country:US
Practice Address - Phone:802-777-6639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101-0030149363LF0000X
MARN2299514363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1010942Medicaid
VTQ26807Medicare UPIN
VT1010942Medicaid