Basic Information
| Provider Information | |||||||||
| NPI: | 1982670162 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | WALTER | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1414 NW NORTHRUP ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972092798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032233104 | ||||||||
| FaxNumber: | 5032234619 | ||||||||
| Practice Location | |||||||||
| Address1: | 1414 NW NORTHRUP ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972092798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032233104 | ||||||||
| FaxNumber: | 5032234619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 07/19/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | OR 6013 | OR | Y | Other Service Providers | Specialist |
No ID Information.