Provider Demographics
NPI:1851974018
Name:LARSEN, MICHAEL LEE
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEE
Last Name:LARSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2917 NW 27TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-2012
Mailing Address - Country:US
Mailing Address - Phone:405-658-6010
Mailing Address - Fax:
Practice Address - Street 1:2808 NW 31ST ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-7407
Practice Address - Country:US
Practice Address - Phone:405-848-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist