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General NPI Number Information
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NPI Number | 1700050333
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Entity Type | Individual
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Provider Name | ILSE A LARSON M.D.
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Gender | Female
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Dates
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Enumeration Date | 04/15/2008
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Last Update Date | 01/21/2020
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Provider Practice Location Address
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Address Line | 3181 SW SAM JACKSON PARK ROAD
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City | PORTLAND
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State | OR
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Zip | 97239-3098
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Country | US
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Telephone | 503-494-6513
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Fax | 503-494-1542
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Provider Business Mailing Address
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Address Line | 2330 POST ST STE 320
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City | SAN FRANCISCO
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State | CA
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Zip | 94115-3466
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Country | US
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Telephone |
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Fax |
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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 | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | MD167663
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | A103087
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License Number State | CA
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