Provider Demographics
NPI:1598728966
Name:LARSON, LAWRENCE ANDREW (PT)
Entity Type:Individual
Prefix:MR
First Name:LAWRENCE
Middle Name:ANDREW
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 1:123 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2652
Mailing Address - Country:US
Mailing Address - Phone:207-373-6183
Mailing Address - Fax:207-673-6178
Practice Address - Street 1:123 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011
Practice Address - Country:US
Practice Address - Phone:207-373-6183
Practice Address - Fax:207-373-6178
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT1806225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432015500Medicaid