Provider Demographics
NPI:1336464544
Name:LARSON, AMANDA CELEST ROOF (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:CELEST ROOF
Last Name:LARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:AMANDA
Other - Middle Name:CELEST
Other - Last Name:ROOF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:315 MARTIN LUTHER KING JR WAY
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4234
Mailing Address - Country:US
Mailing Address - Phone:253-403-1000
Mailing Address - Fax:
Practice Address - Street 1:315 MARTIN LUTHER KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4234
Practice Address - Country:US
Practice Address - Phone:253-403-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA43587207X00000X
WI65700207X00000X
WAMD60482537207X00000X, 207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic Surgery
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery