Healthcare Provider Details

I. General information

NPI: 1760528855
Provider Name (Legal Business Name): JAMES C. LARSEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 08/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 OAK ST.
SUNDANCE WY
82729-0517
US

IV. Provider business mailing address

PO BOX 517
SUNDANCE WY
82729-0517
US

V. Phone/Fax

Practice location:
  • Phone: 307-283-3501
  • Fax: 307-283-2255
Mailing address:
  • Phone: 307-283-3501
  • Fax: 307-283-2489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4487A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: