Provider Demographics
NPI:1093708422
Name:ROGER K LARSON MD PS
Entity Type:Organization
Organization Name:ROGER K LARSON MD PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:K
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:206-244-5477
Mailing Address - Street 1:14212 AMBAUM BLVD SW
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-1449
Mailing Address - Country:US
Mailing Address - Phone:206-244-5477
Mailing Address - Fax:
Practice Address - Street 1:14212 AMBAUM BLVD SW
Practice Address - Street 2:SUITE 201
Practice Address - City:BURIEN
Practice Address - State:WA
Practice Address - Zip Code:98166-1449
Practice Address - Country:US
Practice Address - Phone:206-244-5477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00007073207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA011899328OtherRR MEDICARE
WA7132384Medicaid
A04970Medicare UPIN
WA7132384Medicaid