Provider Demographics
NPI:1104021765
Name:LARSON, LYNN M (DO)
Entity Type:Individual
Prefix:DR
First Name:LYNN
Middle Name:M
Last Name:LARSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:LYNN
Other - Middle Name:M
Other - Last Name:CORACI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:818 W KING ST STE 103
Mailing Address - Street 2:
Mailing Address - City:OWOSSO
Mailing Address - State:MI
Mailing Address - Zip Code:48867-2159
Mailing Address - Country:US
Mailing Address - Phone:989-729-4961
Mailing Address - Fax:989-729-4958
Practice Address - Street 1:818 W KING ST STE 103
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-2159
Practice Address - Country:US
Practice Address - Phone:989-729-4961
Practice Address - Fax:989-729-4958
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-15
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017147207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5101017147OtherLICENSE