Provider Demographics
NPI:1679792881
Name:LARSON, WAYNE (MD,)
Entity type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7514 66TH AVE W
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-8161
Mailing Address - Country:US
Mailing Address - Phone:253-588-9839
Mailing Address - Fax:
Practice Address - Street 1:6210 75TH ST W
Practice Address - Street 2:SUITE A-200
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-8303
Practice Address - Country:US
Practice Address - Phone:253-581-2261
Practice Address - Fax:253-582-7310
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00016569207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine