MEDICARE: DR. AMY JEANNETTE LARSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207PE0004X	Emergency Medical Services (Emergency Medicine) Physician	MD00039071	WA
2	207RC0000X	Cardiovascular Disease Physician	MD00039071	WA
3	207P00000X	Emergency Medicine Physician	MD00039071	WA

General Provider Information

NPI Number	:	1043356819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. AMY JEANNETTE LARSON M.D.

Provider Business Mailing Address
First Line	:	18702 N CREEK PKWY
Second Line	:	SUITE 212
City	:	BOTHELL
State	:	WA
Zip	:	98011-8019
Country	:	US
Telephone Number	:	425-486-8868
Fax Number	:

Provider Business Practice Location Address
First Line	:	2930 BUSH MOUNTAIN CT SW
Second Line	:
City	:	TUMWATER
State	:	WA
Zip	:	98512-6731
Country	:	US
Telephone Number	:	360-352-7856
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	07/09/2019

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