Healthcare Provider Details

I. General information

NPI: 1497973416
Provider Name (Legal Business Name): MARK THOMAS LARSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914 S SCHEUBER RD
CENTRALIA WA
98531-9027
US

IV. Provider business mailing address

6229 SWAYNE DRIVE NE
OLYMPIA WA
98516
US

V. Phone/Fax

Practice location:
  • Phone: 360-330-8785
  • Fax: 360-330-8784
Mailing address:
  • Phone: 360-438-2865
  • Fax: 360-330-8684

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PH0002X
TaxonomyHospice and Palliative Medicine (Emergency Medicine) Physician
License NumberMD00031468
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: