Healthcare Provider Details

I. General information

NPI: 1326808163
Provider Name (Legal Business Name): KYLE CAMERON LARSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2024
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 S CHIPETA WAY RM 2S010
SALT LAKE CITY UT
84108-1287
US

IV. Provider business mailing address

295 S CHIPETA WAY RM 2S010
SALT LAKE CITY UT
84108-1287
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-2121
  • Fax:
Mailing address:
  • Phone: 801-581-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number14239367-1205
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: