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General NPI Number Information
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NPI Number | 1699194530
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Entity Type | Individual
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Provider Name | DUSTIN LARSEN
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Gender | Male
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Dates
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Enumeration Date | 04/08/2014
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Last Update Date | 05/08/2025
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Provider Practice Location Address
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Address Line | 2199 N MERRIT CRK LOOP
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City | COEUR D ALENE
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State | ID
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Zip | 83814-4949
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Country | US
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Telephone | 208-665-7546
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Fax |
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Provider Business Mailing Address
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Address Line | 1899 TATE BLVD SE # 2110
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City | HICKORY
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State | NC
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Zip | 28602-4200
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Country | US
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Telephone | 828-328-4449
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Fax | 828-328-4809
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | M-13761
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 2023-01420
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License Number State | NC
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