Provider Demographics
NPI:1720458847
Name:LARSEN, CARA
Entity Type:Individual
Prefix:
First Name:CARA
Middle Name:
Last Name:LARSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1778
Mailing Address - Street 2:
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-1778
Mailing Address - Country:US
Mailing Address - Phone:807-960-7108
Mailing Address - Fax:
Practice Address - Street 1:68-1845 WAIKOLOA RD
Practice Address - Street 2:
Practice Address - City:WAIKOLOA
Practice Address - State:HI
Practice Address - Zip Code:96738-5584
Practice Address - Country:US
Practice Address - Phone:808-557-8110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-01
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HILMT #4621174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI225700000XOtherTAXONOMY