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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 COUNT Y 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 MD FAMILY _MEDICINE MD00035733
<br />t.ast name , First, Ml T ille (MD,DO, NO, NP, PA) Specialty Wash ington State
<br />(Provider must have (Peds , Fam Med, Medical License Number
<br />prescription writing GP, Other (specify)
<br />privileges)
<br />Last name, First, Ml Tille (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 />Last name, First, Ml Title (MO,OO, 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 />Last name, First , Ml Title (MD,0O, 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 />Last name, First, Ml Tille (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 />Last name, Ffrst, Ml 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 />Last name, First, Ml Tille (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 />Last name, First, Ml Tille (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)
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