Provider Demographics
NPI:1972545978
Name:LARSON, KIMBERLY D (WHCNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:D
Last Name:LARSON
Suffix:
Gender:F
Credentials:WHCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 E NEVADA ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-1024
Mailing Address - Country:US
Mailing Address - Phone:541-864-8900
Mailing Address - Fax:541-245-3315
Practice Address - Street 1:3170 STATE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8450
Practice Address - Country:US
Practice Address - Phone:541-864-8900
Practice Address - Fax:541-245-3315
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200250159NP363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORQ18908Medicare UPIN
OR119689Medicare ID - Type Unspecified