Basic Information
| Provider Information | |||||||||
| NPI: | 1780799437 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | HEIDI | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 161 CORPORATE DR | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038016825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034315154 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2 GREAT FALLS PLZ STE 21 | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 042105966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073303950 | ||||||||
| FaxNumber: | 2073303955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 06/11/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD14388 | ME | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 046529 | 01 | ME | ANTHEM | OTHER | 3 5150000 | 05 | ME | MEDICAID | 5904624 | 01 | ME | AETNA | OTHER |