Provider Demographics
NPI:1598967150
Name:LARSEN, NILS J
Entity Type:Individual
Prefix:MR
First Name:NILS
Middle Name:J
Last Name:LARSEN
Suffix:
Gender:M
Credentials:
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 1111
Mailing Address - Street 2:
Mailing Address - City:ANACORTES
Mailing Address - State:WA
Mailing Address - Zip Code:98221-6111
Mailing Address - Country:US
Mailing Address - Phone:360-293-5866
Mailing Address - Fax:
Practice Address - Street 1:321 W WASHINGTON ST
Practice Address - Street 2:STE. 334
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5920
Practice Address - Country:US
Practice Address - Phone:360-293-5866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA3744225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA41213OtherL & I PROVIDER NUMBER