Provider Demographics
NPI:1700436227
Name:LARSON, ADAM MICHAEL
Entity type:Individual
Prefix:MR
First Name:ADAM
Middle Name:MICHAEL
Last Name:LARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2041 BRANDING IRON WAY
Mailing Address - Street 2:
Mailing Address - City:PLUMAS LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95961-9162
Mailing Address - Country:US
Mailing Address - Phone:513-748-4907
Mailing Address - Fax:
Practice Address - Street 1:3650 AUBURN BLVD # C208
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95821-2069
Practice Address - Country:US
Practice Address - Phone:916-300-6576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty