Healthcare Provider Details

I. General information

NPI: 1780685859
Provider Name (Legal Business Name): LAURIE DENISE LARSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 07/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 S MARYLAND PKWY STE 420
LAS VEGAS NV
89109-2307
US

IV. Provider business mailing address

3131 LA CANADA ST STE 217
LAS VEGAS NV
89169-2578
US

V. Phone/Fax

Practice location:
  • Phone: 702-796-8669
  • Fax: 702-796-9517
Mailing address:
  • Phone: 702-796-8669
  • Fax: 702-796-9517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number7216
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: