Provider Demographics
NPI:1356312532
Name:KRUSHOLM, LARS ERIK (PT)
Entity Type:Individual
Prefix:MR
First Name:LARS
Middle Name:ERIK
Last Name:KRUSHOLM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MEDICAL DEPT
Mailing Address - Street 2:USS KITTY HAWK CV-63
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96634
Mailing Address - Country:US
Mailing Address - Phone:901-855-1755
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL DEPT
Practice Address - Street 2:USS KITTY HAWK CV-63
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96634
Practice Address - Country:US
Practice Address - Phone:901-855-1755
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 23727225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT 23727OtherPT STATE LICENSE