Provider Demographics
NPI:1578708343
Name:LARSON, RYAN R (DPT)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:R
Last Name:LARSON
Suffix:
Gender:M
Credentials:DPT
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 450
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-0450
Mailing Address - Country:US
Mailing Address - Phone:360-698-6630
Mailing Address - Fax:360-698-7002
Practice Address - Street 1:4409 NW ANDERSON HILL RD
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-6807
Practice Address - Country:US
Practice Address - Phone:360-698-6630
Practice Address - Fax:360-698-7002
Is Sole Proprietor?:No
Enumeration Date:2008-12-09
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60428438225100000X
IA004189225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8925298Medicare PIN