Provider Demographics
NPI:1093183956
Name:FERGUSON, LARRY NICKOLAS (PTA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:NICKOLAS
Last Name:FERGUSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9206
Mailing Address - Country:US
Mailing Address - Phone:304-757-6805
Mailing Address - Fax:
Practice Address - Street 1:300 SEVILLE RD
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9206
Practice Address - Country:US
Practice Address - Phone:304-757-6805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002142225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant