Provider Demographics
NPI:1528057213
Name:LARSON, PENNY LEE (MD)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:LEE
Last Name:LARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1756 MAGENTA DR
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-4915
Mailing Address - Country:US
Mailing Address - Phone:530-300-8576
Mailing Address - Fax:
Practice Address - Street 1:12646 THORNBERG WAY
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95742-7839
Practice Address - Country:US
Practice Address - Phone:916-238-6070
Practice Address - Fax:916-238-6070
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01051820A207V00000X
GA55075207V00000X
CAA939852083A0300X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD 000Medicare UPIN
CA156037Medicare UPIN