Basic Information
| Provider Information | |||||||||
| NPI: | 1063412963 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARSSON | ||||||||
| FirstName: | RICHARD | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OLEAN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147601513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163720141 | ||||||||
| FaxNumber: | 7163726421 | ||||||||
| Practice Location | |||||||||
| Address1: | 12 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FRANKLINVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147371224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166762212 | ||||||||
| FaxNumber: | 7166762432 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 02/16/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 003239 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 02220780 | 05 | NY | MEDICAID |