Healthcare Provider Details

I. General information

NPI: 1164561734
Provider Name (Legal Business Name): TRUDY LARSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 W 5TH ST 12C
RENO NV
89503-4407
US

IV. Provider business mailing address

580 W 5TH ST 12C
RENO NV
89503-4407
US

V. Phone/Fax

Practice location:
  • Phone: 775-786-4673
  • Fax:
Mailing address:
  • Phone: 775-786-4673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number4917
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: