Provider Demographics
NPI:1043356819
Name:LARSON, AMY JEANNETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:JEANNETTE
Last Name:LARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:JEANNETTE
Other - Last Name:LOENDORF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:18702 N CREEK PKWY
Mailing Address - Street 2:SUITE 212
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-8019
Mailing Address - Country:US
Mailing Address - Phone:425-486-8868
Mailing Address - Fax:
Practice Address - Street 1:2930 BUSH MOUNTAIN CT SW
Practice Address - Street 2:
Practice Address - City:TUMWATER
Practice Address - State:WA
Practice Address - Zip Code:98512-6731
Practice Address - Country:US
Practice Address - Phone:360-352-7856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039071207PE0004X, 207RC0000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAH33956Medicare ID - Type Unspecified