MEDICARE: DR. WAYNE 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	207Q00000X	Family Medicine Physician	MD00016569	WA

General Provider Information

NPI Number	:	1679792881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WAYNE LARSON M.D,

Provider Business Mailing Address
First Line	:	7514 66TH AVE W
Second Line	:
City	:	LAKEWOOD
State	:	WA
Zip	:	98499-8161
Country	:	US
Telephone Number	:	253-588-9839
Fax Number	:

Provider Business Practice Location Address
First Line	:	6210 75TH ST W
Second Line	:	SUITE A-200
City	:	LAKEWOOD
State	:	WA
Zip	:	98499-8303
Country	:	US
Telephone Number	:	253-581-2261
Fax Number	:	253-582-7310

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

Provider Enumeration Date	:	04/25/2007
Last Update Date	:	07/08/2007

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