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2018
<br />WASHINGTON STATE DEPARTMENT OF HEALTH
<br />OFFICE OF IMMUNIZATION AND CHILD PROFILE
<br />Organization Name: KITTITAS COUNTY HEALTH DEPARTMENT
<br />Clinic/Facility Name: KITTITAS COUNTY HEALTH DEPARTMENT
<br />PIN: 163000
<br />PROVIDERS WITHIN THE PRACTICE
<br />Please print or type the names, titles, specialties, and Washington State medical license numbers of licensed health providers in
<br />your practice who are authorized to write prescriptions and may provide immunizations. Attach additional copies of this sheet as
<br />needed.
<br />LARSON, MARK W
<br />Last name, First,
<br />Last name, First, MI
<br />Last name,
<br />First,
<br />MI
<br />Last name,
<br />First,
<br />MI
<br />Last name,
<br />First,
<br />MI
<br />Last name,
<br />First,
<br />MI
<br />Last name,
<br />First,
<br />MI
<br />Last name,
<br />First,
<br />MI
<br />MD FAMILY—MEDICINE MD00035733
<br />Title (MD,DO, ND, NP, PA)
<br />Specialty Washington State
<br />(Provider must have
<br />(Peds, Fam Med, Medical License Number
<br />prescription writing
<br />GP, Other (specify)
<br />privileges)
<br />Title (MD,DO, ND, NP, PA)
<br />Specialty Washington State
<br />(Provider must have
<br />(Peds, Fam Med, Medical License Number
<br />prescription writing
<br />GP, Other (specify)
<br />privileges)
<br />Title (MD,DO, ND, NP, PA) Specialty
<br />(Provider must have (Peds, Fam Med,
<br />prescription writing GP, Other (specify)
<br />privileges)
<br />Washington State
<br />Medical License Number
<br />Title (MD,DO, NO, NP, PA) Specialty Washington State
<br />(Provider must have (Peds, Fam Med, Medical License Number
<br />prescription writing GP, Other (specify)
<br />privileges)
<br />Title (MD,DO, ND, NP, PA) Specialty Washington State
<br />(Provider must have (Peds, Fam Med, Medical License Number
<br />prescription writing GP, Other (specify)
<br />privileges)
<br />Title (MD,DO, ND, NP, PA) Specialty
<br />(Provider must have (Peds, Fam Med,
<br />prescription writing GP, Other (specify)
<br />privileges)
<br />Washington State
<br />Medical License Number
<br />Title (MD,DO, ND, NP, PA) Specialty Washington State
<br />(Provider must have (Peds, Fam Med, Medical License Number
<br />prescription writing GP, Other (specify)
<br />privileges)
<br />Title (MD,DO, ND, NP, PA) Specialty Washington State
<br />(Provider must have (Peds, Fam Med, Medical License Number
<br />prescription writing GP, Other (specify)
<br />privileges)
<br />
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