Provider Demographics
NPI:1437509759
Name:LARSEN, KACI RAE (MD)
Entity Type:Individual
Prefix:
First Name:KACI
Middle Name:RAE
Last Name:LARSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25500 N NORTERRA DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-8200
Mailing Address - Country:US
Mailing Address - Phone:623-277-2370
Mailing Address - Fax:
Practice Address - Street 1:710 W BELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-3507
Practice Address - Country:US
Practice Address - Phone:800-233-3264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-17
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018044700207Q00000X
AZ64070207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine