Provider Demographics
NPI:1174177471
Name:LARSON, BRYAN DUANE (DNP-PMHNP)
Entity type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:DUANE
Last Name:LARSON
Suffix:
Gender:M
Credentials:DNP-PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1581
Mailing Address - Street 2:
Mailing Address - City:MATTAWA
Mailing Address - State:WA
Mailing Address - Zip Code:99349-0960
Mailing Address - Country:US
Mailing Address - Phone:509-932-4119
Mailing Address - Fax:
Practice Address - Street 1:210 GOVERNMENT ROAD
Practice Address - Street 2:
Practice Address - City:MATTAWA
Practice Address - State:WA
Practice Address - Zip Code:99349-0906
Practice Address - Country:US
Practice Address - Phone:509-932-4499
Practice Address - Fax:509-932-5363
Is Sole Proprietor?:No
Enumeration Date:2019-07-25
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60980845363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2144830Medicaid