Provider Demographics
NPI:1538422118
Name:LARSEN, JOHN KENYON (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:KENYON
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:KENNY
Other - Middle Name:
Other - Last Name:LARSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:1470 MEDICAL PARKWAY
Mailing Address - Street 2:SUITE 265
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89703-4648
Mailing Address - Country:US
Mailing Address - Phone:775-445-5464
Mailing Address - Fax:775-445-5474
Practice Address - Street 1:1470 MEDICAL PKWY STE 265
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-4648
Practice Address - Country:US
Practice Address - Phone:775-445-5464
Practice Address - Fax:775-445-5474
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2019-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003922363A00000X
NVPA2016363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1538422118Medicaid
VAVV8201AMedicare PIN