1306932488 NPI number — LAWRENCE LARSON DO

Table of content: LAWRENCE LARSON DO (NPI 1306932488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306932488 NPI number — LAWRENCE LARSON DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARSON
Provider First Name:
LAWRENCE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306932488
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/21/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
316 MARTIN LUTHER KING JR WAY
Provider Second Line Business Mailing Address:
212
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-383-5777
Provider Business Mailing Address Fax Number:
253-627-0855

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
316 MARTIN LUTHER KING JR WAY
Provider Second Line Business Practice Location Address:
212
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-383-5777
Provider Business Practice Location Address Fax Number:
253-627-0855
Provider Enumeration Date:
10/05/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207K00000X , with the licence number:  OP00000821 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2080P0201X , with the licence number: OP00000821 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10255717 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".