Healthcare Provider Details

I. General information

NPI: 1790871093
Provider Name (Legal Business Name): STACIA GILDE MARIE LARSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S BOLTWOOD ST
HASTINGS MI
49058-1926
US

IV. Provider business mailing address

100 CHERRY ST SE
GRAND RAPIDS MI
49503-4526
US

V. Phone/Fax

Practice location:
  • Phone: 269-945-4220
  • Fax: 269-945-4229
Mailing address:
  • Phone: 616-965-8200
  • Fax: 616-742-9967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301087952
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: