Basic Information
| Provider Information | |||||||||
| NPI: | 1245693902 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | KRISTA | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 NE KNOTT ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972123014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032533910 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 301 NE KNOTT ST STE 4102 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972123014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3055620588 | ||||||||
| FaxNumber: | 3522651107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2016 | ||||||||
| LastUpdateDate: | 01/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | MD200083 | OR | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.