Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207P00000X | Emergency Physician | 25MA10897300 | NJ |
Y | 207P00000X | Emergency Physician | 29862 | WV |
N | 207P00000X | Emergency Physician | 304201 | NY |
NPI | 1003279456 |
---|---|
Provider Name | Dr. Cody Braxton Larsen |
First Address | San Francisco, CA 94121-2314 |
Second Address | Glen Dale, WV 26038-1660 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/04/2016 |
Last Update Date | 11/01/2021 |