Provider Demographics
NPI:1790030716
Name:LARSON, NATHAN L (DPM)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:L
Last Name:LARSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:520 BIRCHWOOD AVE STE A
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-1700
Mailing Address - Country:US
Mailing Address - Phone:360-734-3668
Mailing Address - Fax:360-676-8941
Practice Address - Street 1:520 BIRCHWOOD AVE STE A
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1700
Practice Address - Country:US
Practice Address - Phone:360-734-3668
Practice Address - Fax:360-676-8941
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA860213ES0103X
WAPO60697482213ES0103X
NE355213ES0103X
KS12-00413213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NENA2775002Medicare Oscar/Certification