Shane Lyle Larson, M.D.

Primary specialty

Sports Medicine (Family Medicine) PhysicianTaxonomy code 207QS0010X

License

67238 Issued in GA

Practice address

576 Jefferson Ave
Fort Eustis, VA 23604-1373

Phone

(757) 820-1043

Fax

(757) 820-1122

NPI assigned

Jun 8, 2010

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in HI

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1275955200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1651017600000",
    "number": "1750601191",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "576 JEFFERSON AVE",
            "city": "FORT EUSTIS",
            "state": "VA",
            "postal_code": "236041373",
            "telephone_number": "757-820-1043",
            "fax_number": "757-820-1122"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "576 JEFFERSON AVE",
            "city": "FORT EUSTIS",
            "state": "VA",
            "postal_code": "236041373",
            "telephone_number": "757-820-1043",
            "fax_number": "757-820-1122"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "2817 Reilly Road",
            "address_purpose": "LOCATION",
            "city": "FORT BRAGG",
            "state": "NC",
            "postal_code": "28310",
            "country_code": "US",
            "telephone_number": "910-643-1427",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "LARSON",
        "first_name": "SHANE",
        "middle_name": "LYLE",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2010-06-08",
        "last_updated": "2022-04-27",
        "certification_date": "2022-04-27",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "GA",
            "license": "67238",
            "primary": false
        },
        {
            "code": "207QS0010X",
            "taxonomy_group": "",
            "desc": "Family Medicine, Sports Medicine",
            "state": "GA",
            "license": "67238",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "www.us.army.mil",
            "affiliation": "N",
            "address_1": "2817 Reilly Road",
            "city": "FORT BRAGG",
            "state": "NC",
            "country_code": "US",
            "postal_code": "28310",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Michael Joseph Konetsky, PT, DPT, OCS
• Dylan Kordes
• 01/Cathleen Ann Labate, DDS
• Jason C Lacourse, DMD
• Darii Ann Lane, MD
• Vincent Nevin Lattanzi, PROPHY TECH
• Cara Lawn
• Michael Jeremy Lawson, MD
• Tamar Christine Ledbetter, M.D., MFT
• Jonathan D Lesher

• Sports Medicine (Family Medicine) Physician in Fort Eustis, VA
• Providers in Fort Eustis, VA by specialty
• Sports Medicine (Family Medicine) Physician in Virginia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 27, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.