Healthcare Provider Details

I. General information

NPI: 1194635110
Provider Name (Legal Business Name): ANNA LARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANNA UNGERMAN

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1727 JACKI CT NE
OLYMPIA WA
98506-3611
US

IV. Provider business mailing address

1727 JACKI CT NE
OLYMPIA WA
98506-3611
US

V. Phone/Fax

Practice location:
  • Phone: 801-472-7933
  • Fax:
Mailing address:
  • Phone: 801-472-7933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number60692878
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: