Provider Demographics
NPI:1922439264
Name:LARSEN, JASON M (CRNA, DNP)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:LARSEN
Suffix:
Gender:M
Credentials:CRNA, DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 NOVUS DR STE 2
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-8237
Mailing Address - Country:US
Mailing Address - Phone:423-283-0776
Mailing Address - Fax:423-283-0549
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-8237
Practice Address - Country:US
Practice Address - Phone:859-323-5956
Practice Address - Fax:859-323-1080
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN19921367500000X
KY4018931367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ016239Medicaid
TNQ016239Medicaid