Provider Demographics
NPI:1477525681
Name:LARSON, PAUL MATTHEW (PT)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:MATTHEW
Last Name:LARSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2395
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-2395
Mailing Address - Country:US
Mailing Address - Phone:928-522-0364
Mailing Address - Fax:928-522-0439
Practice Address - Street 1:2510 E 7TH AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-3719
Practice Address - Country:US
Practice Address - Phone:928-522-0364
Practice Address - Fax:928-522-0439
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ39422251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ78178Medicare ID - Type UnspecifiedPHYSICAL THERAPIST