Provider Demographics
NPI:1528331469
Name:LARSSON, CHARLES EVERT (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:EVERT
Last Name:LARSSON
Suffix:
Gender:M
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:P O BOX 1620
Mailing Address - Street 2:
Mailing Address - City:LACONNER
Mailing Address - State:WA
Mailing Address - Zip Code:98862-1620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:528 MYRTLE AVENUE
Practice Address - Street 2:
Practice Address - City:LA CONNER
Practice Address - State:WA
Practice Address - Zip Code:98257
Practice Address - Country:US
Practice Address - Phone:360-466-3136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-22
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00022768207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine