Individual
DR. SHANE LYLE LARSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
576 JEFFERSON AVE, FORT EUSTIS, VA 23604-1373
(757) 820-1043
(757) 820-1122
Mailing address
576 JEFFERSON AVE, FORT EUSTIS, VA 23604-1373
(757) 820-1043
(757) 820-1122
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
67238
GA
207QS0010X
Sports Medicine (Family Medicine) Physician
Primary
67238
GA
Other
Enumeration date
06/08/2010
Last updated
04/27/2022
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