Healthcare Provider Details

I. General information

NPI: 1245693902
Provider Name (Legal Business Name): KRISTA NICOLE LARSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 NE KNOTT ST STE 4102
PORTLAND OR
97212-3014
US

IV. Provider business mailing address

301 NE KNOTT ST
PORTLAND OR
97212-3014
US

V. Phone/Fax

Practice location:
  • Phone: 305-562-0588
  • Fax: 352-265-1107
Mailing address:
  • Phone: 503-253-3910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD200083
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: