1770812661 NPI number — DR. MALORIE ANN LARSON DPT

Table of content: DR. MALORIE ANN LARSON DPT (NPI 1770812661)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770812661 NPI number — DR. MALORIE ANN LARSON DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LARSON
Provider First Name:
MALORIE
Provider Middle Name:
ANN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOWLING
Provider Other First Name:
MALORIE
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1770812661
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4220 132ND ST SE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
MILL CREEK
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98012-8999
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-357-9380
Provider Business Mailing Address Fax Number:
425-357-9382

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7315 212TH ST SW
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
EDMONDS
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98026-7610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-774-3226
Provider Business Practice Location Address Fax Number:
425-670-1406
Provider Enumeration Date:
12/23/2009

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: 225100000X , with the licence number:  PT 60122259 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0368933 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 4518930 . This is a "AETNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0260899 . This is a "DEPARTMENT OF LABOR AND INDUSTRIES" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0369225 . This is a "L & I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 616182300 . This is a "FEDERAL DEPARTMENT OF LABOR" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0991DO . This is a "REGENCE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 12036365 . This is a "CAQH" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 12036365 . This is a "CIGNA" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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