Provider Demographics
NPI:1215903752
Name:LARSON, KIMBERLY C (PAC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:C
Last Name:LARSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 S UNION
Mailing Address - Street 2:STE 300
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1387
Mailing Address - Country:US
Mailing Address - Phone:253-756-0888
Mailing Address - Fax:253-752-1704
Practice Address - Street 1:2420 S UNION
Practice Address - Street 2:STE 300
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1387
Practice Address - Country:US
Practice Address - Phone:253-756-0888
Practice Address - Fax:253-752-1704
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004275363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0256770OtherSTATE L&I
WA0256322OtherSTATE L&I
WAG8886306Medicare PIN
WA0256770OtherSTATE L&I
S50820Medicare UPIN