Provider Demographics
NPI:1356522049
Name:LARSON, TANYA RENE (LMP)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:RENE
Last Name:LARSON
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:TANYA
Other - Middle Name:RENE
Other - Last Name:KLEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMP
Mailing Address - Street 1:120 N. OAK ST.
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WA
Mailing Address - Zip Code:98233
Mailing Address - Country:US
Mailing Address - Phone:425-319-6809
Mailing Address - Fax:360-755-1305
Practice Address - Street 1:120 N. OAK ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98233
Practice Address - Country:US
Practice Address - Phone:425-319-6809
Practice Address - Fax:360-755-1305
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00020919174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist