Provider Demographics
NPI:1245693902
Name:LARSON, KRISTA NICOLE (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTA
Middle Name:NICOLE
Last Name:LARSON
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 1:301 NE KNOTT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3014
Mailing Address - Country:US
Mailing Address - Phone:503-253-3910
Mailing Address - Fax:
Practice Address - Street 1:301 NE KNOTT ST STE 4102
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-3014
Practice Address - Country:US
Practice Address - Phone:305-562-0588
Practice Address - Fax:352-265-1107
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD200083207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology