Provider Demographics
NPI:1720189749
Name:LARSEN, PAUL RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:RICHARD
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 421
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0421
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:509-944-9644
Practice Address - Street 1:100 W SOUTH AVE
Practice Address - Street 2:
Practice Address - City:CHEWELAH
Practice Address - State:WA
Practice Address - Zip Code:99019
Practice Address - Country:US
Practice Address - Phone:509-935-8111
Practice Address - Fax:509-935-8402
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00037362207VX0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8241929Medicaid
WACE9078OtherRAILROAD MEDICARE
WA129298OtherLABOR & INDUSTRIES ID #
WAAB10394Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
WAAB10392Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
WA129298OtherLABOR & INDUSTRIES ID #
WAAB10391Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
WAAB10393Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
WAG72208Medicare UPIN
WA501813Medicare Oscar/Certification
WA8241929Medicaid