Individual
ELISE A LARSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
4805 NE GLISAN ST STE BG05, PORTLAND, OR 97213-2933
(503) 215-2392
Mailing address
PO BOX 3158, PORTLAND, OR 97208-3158
(503) 215-6494
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
MD195529
OR
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
03/31/2016
Last updated
10/02/2020
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