Provider Demographics
NPI:1093792632
Name:LARSON, GAYLE S (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:GAYLE
Middle Name:S
Last Name:LARSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:GAYLE
Other - Middle Name:S
Other - Last Name:HUNT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0000
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4501
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-0000
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4501
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-26
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200460012CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1407812365OtherNBMC NPI NUMBER-GROUP
OR027893Medicaid
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR1407812365OtherNBMC NPI NUMBER-GROUP
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
ORR132539Medicare PIN
OR0577260001Medicare NSC