Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | ME100673 | FL |
N | 111NI0900X | Internist | ME100673 | FL |
Y | 207RG0100X | Gastroenterologist | 018950 | ME |
NPI | 1033206941 |
---|---|
Provider Name | Jean M Larson |
First Address | Brewer, ME 04412-1006 |
Second Address | Bangor, ME 04401-6630 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/10/2006 |
Last Update Date | 28/02/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1033206941 | (05) | ME |
280216300 | (05) | FL |
RES000 | (02) | FL |