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2016
<br />WASHINGTON STATE DEPARTMENT OF HEALTH
<br />OFFICE OF IMMUNIZATION AND CHILD PROFILE
<br />Organization Name: KITTITAS VALLEY HEAL THCARE
<br />Clinic/Facility Name: KITTITAS COUNTY PUBLIC HEALTH
<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, MI
<br />Last name, First, MI
<br />Last name, First, MI
<br />Last name, First, MI
<br />Last name, First, MI
<br />Last name, First, MI
<br />Last name, First, MI
<br />Last name, First, MI
<br />MD
<br />Title (MO,OO, NO, NP, PA)
<br />(Provider must have
<br />prescription writing
<br />privileges)
<br />Title (MO,OO, NO, NP, PA)
<br />(Provider must have
<br />prescription writing
<br />privileges)
<br />Title (MO,OO, NO, NP, PA)
<br />(Provider must have
<br />prescription writing
<br />privileges)
<br />Title (MO,OO, NO, NP, PA)
<br />(Provider must have
<br />prescription writing
<br />privileges)
<br />Title (MO,OO, NO, NP, PA)
<br />(Provider must have
<br />prescription writing
<br />privileges)
<br />Title (MO,OO, NO, NP, PA)
<br />(Provider must have
<br />prescription writing
<br />privileges)
<br />Title (MO,OO, NO, NP, PA)
<br />(Provider must have
<br />prescription writing
<br />privileges)
<br />Title (MO,OO, NO, NP, PA)
<br />(Provider must have
<br />prescription writing
<br />privileges)
<br />FAMILY_MEDICINE MD00035733
<br />Specialty Washington State
<br />(Peds, Fam Med, Medical License Number
<br />GP, Other (specify)
<br />Specialty Washington State
<br />(Peds, Fam Med, Medical License Number
<br />GP, Other (specify)
<br />Specialty Washington State
<br />(Peds, Fam Med, Medical License Number
<br />GP, Other (specify)
<br />Specialty Washington State
<br />(Peds, Fam Med, Medical License Number
<br />GP, Other (specify)
<br />Specialty Washington State
<br />(Peds, Fam Med, Medical License Number
<br />GP, Other (specify)
<br />Specialty Washington State
<br />(Peds, Fam Med , Medical License Number
<br />GP, Other (specify)
<br />Specialty Washington State
<br />(Peds, Fam Med, Medical License Number
<br />GP, Other (specify)
<br />Specialty Washington State
<br />(Peds, Fam Med, Medical License Number
<br />GP, Other (specify)
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