Provider Demographics
NPI:1053576504
Name:LARSON, KIRT W (MSN,FNP-C)
Entity type:Individual
Prefix:
First Name:KIRT
Middle Name:W
Last Name:LARSON
Suffix:
Gender:M
Credentials:MSN,FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13352 SOUTH 5600 WEST
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096
Mailing Address - Country:US
Mailing Address - Phone:801-446-2760
Mailing Address - Fax:801-446-2762
Practice Address - Street 1:13352 SOUTH 5600 WEST
Practice Address - Street 2:
Practice Address - City:HERRIMAN
Practice Address - State:UT
Practice Address - Zip Code:84096
Practice Address - Country:US
Practice Address - Phone:801-446-2760
Practice Address - Fax:801-446-2762
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-24
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT211451-4405363L00000X
UT2114514405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1053576504Medicaid
UT1053576504Medicaid