Provider Demographics
NPI:1417181082
Name:LARSON, PAUL ERIK (ATC)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ERIK
Last Name:LARSON
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:673 GREAT BEND TPKE
Mailing Address - Street 2:
Mailing Address - City:PLEASANT MOUNT
Mailing Address - State:PA
Mailing Address - Zip Code:18453-4544
Mailing Address - Country:US
Mailing Address - Phone:570-448-2598
Mailing Address - Fax:570-281-7102
Practice Address - Street 1:101 BROOKLYN STREET/BUSINESS ROUTE 6
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:PA
Practice Address - Zip Code:18407
Practice Address - Country:US
Practice Address - Phone:570-282-4500
Practice Address - Fax:570-281-7102
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART002358A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer