Healthcare Provider Details

I. General information

NPI: 1891358479
Provider Name (Legal Business Name): KAITLIN JESSICA LARSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2019
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 E ROOSEVELT ST
PHOENIX AZ
85008-4973
US

IV. Provider business mailing address

2631 N 70TH PL
SCOTTSDALE AZ
85257-1343
US

V. Phone/Fax

Practice location:
  • Phone: 602-344-5011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number011938
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number011938
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: