Provider Demographics
NPI:1922544600
Name:LARSEN, BRENDON (PTA)
Entity Type:Individual
Prefix:
First Name:BRENDON
Middle Name:
Last Name:LARSEN
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 1:326 CHARDONNAY AVE
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-9515
Mailing Address - Country:US
Mailing Address - Phone:509-786-6626
Mailing Address - Fax:
Practice Address - Street 1:326 CHARDONNAY AVE
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-9515
Practice Address - Country:US
Practice Address - Phone:509-786-6626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-18
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID4839225200000X
WAP160719840225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant