Basic Information
| Provider Information | |||||||||
| NPI: | 1710920970 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 55310 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352555310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057319701 | ||||||||
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| Practice Location | |||||||||
| Address1: | 619 19TH STREET SOUTH | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059344011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 05/20/2011 | ||||||||
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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 | 363LA2200X | 1-040511 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 051505099 | 01 | AL | BLUE CROSS | OTHER | 051551249 | 05 | AL | MEDICAID | 500021681 | 01 | AL | RAILROAD MEDICARE | OTHER | 051505098 | 01 | AL | BLUE CROSS | OTHER | 891003450 | 05 | AL | MEDICAID |