Provider Demographics
NPI:1851310510
Name:LARSON, LANCE C (MD)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:C
Last Name:LARSON
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 1:1100 9TH AVE
Mailing Address - Street 2:MS:M4-PA
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-2756
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11695 NE 4TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-5268
Practice Address - Country:US
Practice Address - Phone:425-637-1855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00030152207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8169443Medicaid
WA0039581OtherLABOR & INDUSTRY
WALA5079OtherBLUE SHIELD
WAUS0899580OtherAETNA/USHC PCP
WA217112701Medicare PIN
WA8892199Medicare PIN
WA0039581OtherLABOR & INDUSTRY
F89357Medicare UPIN