Provider Demographics
NPI:1194784090
Name:LARSON, MARK W (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:W
Last Name:LARSON
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:716 E MANITOBA AVE
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-3842
Mailing Address - Country:US
Mailing Address - Phone:509-925-3151
Mailing Address - Fax:
Practice Address - Street 1:716 E MANITOBA AVE
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-3842
Practice Address - Country:US
Practice Address - Phone:509-925-3151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035733207Q00000X
WA2520900035733174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8219073Medicaid
WA503878Medicare ID - Type UnspecifiedRURAL HEALTH CLINIC ID #
WAF48818Medicare UPIN
WA8219073Medicaid