Provider Demographics
NPI:1174940282
Name:LARSEN GASTROENTEROLOGY, PLLC
Entity type:Organization
Organization Name:LARSEN GASTROENTEROLOGY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HASTINGS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-758-2200
Mailing Address - Street 1:625 6TH ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2010
Mailing Address - Country:US
Mailing Address - Phone:509-758-2200
Mailing Address - Fax:
Practice Address - Street 1:625 6TH ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2010
Practice Address - Country:US
Practice Address - Phone:509-758-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-26
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 00029346261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2039081Medicaid
ID0027334Medicaid
1125796Medicare PIN
ID0027334Medicaid