Provider Demographics
NPI:1790974764
Name:LARSON, GREGORY THOMAS (LMP)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:THOMAS
Last Name:LARSON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:167 NE KAMIAKEN ST
Mailing Address - Street 2:(MEZZANINE)
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-2611
Mailing Address - Country:US
Mailing Address - Phone:509-332-0555
Mailing Address - Fax:509-334-9522
Practice Address - Street 1:167 NE KAMIAKEN ST
Practice Address - Street 2:(MEZZANINE)
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-2611
Practice Address - Country:US
Practice Address - Phone:509-332-0555
Practice Address - Fax:509-334-9522
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00015575172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker