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General NPI Number Information
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NPI Number | 1790300143
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Entity Type | Individual
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Provider Name | SPENCER LARSON DO
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Gender | Male
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Dates
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Enumeration Date | 06/11/2020
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Last Update Date | 09/11/2023
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Provider Practice Location Address
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Address Line | 2376 N 400 E STE 102
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City | TOOELE
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State | UT
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Zip | 84074-3413
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Country | US
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Telephone | 435-843-1225
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Fax | 435-843-1228
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Provider Business Mailing Address
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Address Line | 267 E VENTURA BLVD
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City | STANSBURY PARK
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State | UT
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Zip | 84074-9327
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Country | US
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Telephone | 801-854-8629
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 13185617-1204
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License Number State | UT
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