Provider Demographics
NPI:1063430890
Name:LARSEN, BRAD RODNEY (PA)
Entity type:Individual
Prefix:
First Name:BRAD
Middle Name:RODNEY
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:801-715-8228
Practice Address - Street 1:1701 E PFLUGERVILLE PKWY
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-8990
Practice Address - Country:US
Practice Address - Phone:512-259-6000
Practice Address - Fax:512-260-6005
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5166627-1206363AM0700X
TXPA02752363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP14720Medicare UPIN
TX8G8218Medicare PIN