Provider Demographics
NPI:1417045659
Name:NIELSON, LARRY D (P T)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:NIELSON
Suffix:
Gender:M
Credentials:P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2747 W BULLARD AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-2268
Mailing Address - Country:US
Mailing Address - Phone:559-261-1425
Mailing Address - Fax:559-261-4573
Practice Address - Street 1:2747 W BULLARD AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-2268
Practice Address - Country:US
Practice Address - Phone:559-261-1425
Practice Address - Fax:559-261-4573
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0PT148110225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT0148110OtherMEDI CAL
CA0PT148110Medicare ID - Type Unspecified