Provider Demographics
NPI:1790981421
Name:MARTIN, LARISA G (MD)
Entity Type:Individual
Prefix:DR
First Name:LARISA
Middle Name:G
Last Name:MARTIN
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 1:13030 MILITARY RD S
Mailing Address - Street 2:STE 210
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98168-3085
Mailing Address - Country:US
Mailing Address - Phone:206-242-6500
Mailing Address - Fax:206-246-7946
Practice Address - Street 1:13030 MILITARY RD S
Practice Address - Street 2:STE 210
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98168-3085
Practice Address - Country:US
Practice Address - Phone:206-242-6500
Practice Address - Fax:206-246-7946
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116018093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine