Healthcare Provider Details

I. General information

NPI: 1790974764
Provider Name (Legal Business Name): GREGORY THOMAS LARSON LMP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 NE KAMIAKEN ST (MEZZANINE)
PULLMAN WA
99163-2611
US

IV. Provider business mailing address

167 NE KAMIAKEN ST (MEZZANINE)
PULLMAN WA
99163-2611
US

V. Phone/Fax

Practice location:
  • Phone: 509-332-0555
  • Fax: 509-334-9522
Mailing address:
  • Phone: 509-332-0555
  • Fax: 509-334-9522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberMA00015575
License Number StateWA

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: