Provider Demographics
NPI:1467647750
Name:LARSON, PHILLIP ERIK (PT A)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:ERIK
Last Name:LARSON
Suffix:
Gender:M
Credentials:PT A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8034 LINDA VISTA RD APT 1A
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-5146
Mailing Address - Country:US
Mailing Address - Phone:858-292-6251
Mailing Address - Fax:
Practice Address - Street 1:13075 EVENING CREEK DR S
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-8101
Practice Address - Country:US
Practice Address - Phone:209-531-4613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT3876225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant