Healthcare Provider Details

I. General information

NPI: 1093026387
Provider Name (Legal Business Name): ANGELA NOEL LARSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

907 GEORGIANA ST
PORT ANGELES WA
98362
US

IV. Provider business mailing address

PO BOX 850
PORT ANGELES WA
98362-0146
US

V. Phone/Fax

Practice location:
  • Phone: 360-565-0999
  • Fax: 360-565-0852
Mailing address:
  • Phone: 360-417-7111
  • Fax: 360-417-7342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD162496
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD60294297
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2015-0417
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: