Provider Demographics
NPI:1467831073
Name:LARSON, IAN MICHAEL (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:IAN
Middle Name:MICHAEL
Last Name:LARSON
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16075 W LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-2828
Mailing Address - Country:US
Mailing Address - Phone:218-966-0700
Mailing Address - Fax:
Practice Address - Street 1:15640 N 7TH ST STE 6
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-3538
Practice Address - Country:US
Practice Address - Phone:602-439-3800
Practice Address - Fax:602-439-3802
Is Sole Proprietor?:No
Enumeration Date:2015-05-28
Last Update Date:2015-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ115252251G0304X, 2251N0400X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology