Basic Information
| Provider Information | |||||||||
| NPI: | 1700933488 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | CYNTHIA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LMP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13044 111TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980346306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2067992562 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11821 NE 128TH ST STE B | ||||||||
| Address2: | |||||||||
| City: | KIRKLAND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980347210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4258142800 | ||||||||
| FaxNumber: | 4258230882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MA00007116 | WA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | REGENCE | 01 | WA | 7695LA | OTHER | 0182278 | 01 | WA | WA DEPT OF L&I | OTHER | REGENCE | 01 | WA | LA6077 | OTHER |