Provider Demographics
NPI:1548535503
Name:LARSEN, BRIANNE K (PA)
Entity type:Individual
Prefix:
First Name:BRIANNE
Middle Name:K
Last Name:LARSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 US HIGHWAY 441 BLDG 100
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-2545
Mailing Address - Country:US
Mailing Address - Phone:352-460-4004
Mailing Address - Fax:352-460-4003
Practice Address - Street 1:1801 US HIGHWAY 441 BLDG 100
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-2545
Practice Address - Country:US
Practice Address - Phone:352-460-4004
Practice Address - Fax:352-460-4003
Is Sole Proprietor?:No
Enumeration Date:2012-03-09
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116914363A00000X
SC3987363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4722PAMedicaid