Provider Demographics
NPI:1326024191
Name:LARSEN, WADE B (MD)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:B
Last Name:LARSEN
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:PO BOX 337
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-0337
Mailing Address - Country:US
Mailing Address - Phone:801-773-4840
Mailing Address - Fax:801-525-8151
Practice Address - Street 1:2121 N 1700 W
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-8803
Practice Address - Country:US
Practice Address - Phone:801-773-4840
Practice Address - Fax:801-525-8151
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT52642531205208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD4988Medicaid
UT005536833Medicare ID - Type Unspecified
UTD4988Medicaid
UT002241033Medicare ID - Type Unspecified
H86315Medicare UPIN