MEDICARE: LARSON DERMATOLOGY, LLC

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	207N00000X	Dermatology Physician

General Provider Information

NPI Number	:	1679405195
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LARSON DERMATOLOGY, LLC

Provider Business Mailing Address
First Line	:	PO BOX 86536
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97286-0536
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5441 S MACADAM AVE STE R
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97239-3822
Country	:	US
Telephone Number	:	541-919-2353
Fax Number	:

Authorized Official
Title or Position	:	OWNER/DERMATOLOGIST
Name	:	KRISTA N LARSON
Credential	:	MD
Telephone Number	:	541-919-2353

Provider Enumeration Date	:	06/01/2026
Last Update Date	:	06/01/2026

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