Provider Demographics
NPI:1982990453
Name:LARSON, CRYSTAL ANN (DO)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:ANN
Last Name:LARSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:ANN
Other - Last Name:FESENBEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3340 E GOLDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-302-0900
Mailing Address - Fax:208-302-0955
Practice Address - Street 1:6348 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8732
Practice Address - Country:US
Practice Address - Phone:208-302-0900
Practice Address - Fax:208-302-0955
Is Sole Proprietor?:No
Enumeration Date:2011-06-23
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS77042084P0800X
ORDO1708712084P0800X
IDO-13572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry