Individual
TYLER ROTH LARSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1289 49TH AVE, SWEET HOME, OR 97386
(541) 451-6250
Mailing address
PO BOX 1189, CORVALLIS, OR 97339-1189
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
10001988A
IN
363A00000X
Physician Assistant
50.004194
OH
363A00000X
Physician Assistant
Primary
PA201515
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000985776
ANTHEM
IN
05
—
300003222
—
IN
Enumeration date
10/31/2014
Last updated
11/27/2023
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