Provider Demographics
NPI:1477033512
Name:BOARDMAN, LARRY DON (PTA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DON
Last Name:BOARDMAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4201 STONEGATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-9503
Mailing Address - Country:US
Mailing Address - Phone:817-924-5440
Mailing Address - Fax:
Practice Address - Street 1:4201 STONEGATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-9503
Practice Address - Country:US
Practice Address - Phone:817-924-5440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2101868225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant