Provider Demographics
NPI:1093715377
Name:LARSON, TIMOTHY A (MAPT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:A
Last Name:LARSON
Suffix:
Gender:M
Credentials:MAPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1122
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-1122
Mailing Address - Country:US
Mailing Address - Phone:509-826-9533
Mailing Address - Fax:509-826-1152
Practice Address - Street 1:11 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841
Practice Address - Country:US
Practice Address - Phone:509-826-9533
Practice Address - Fax:509-826-1152
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006179225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1093715377OtherNPI
WA7081896Medicaid
WAGAB00169OtherMEDICARE OLD PIN
WAS39216Medicare UPIN
WA1093715377OtherNPI