Provider Demographics
NPI:1942415526
Name:RUST, LARRY DONALD (PTA)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:DONALD
Last Name:RUST
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 1:92 LINDA VISTA ST
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-2231
Mailing Address - Country:US
Mailing Address - Phone:510-410-1892
Mailing Address - Fax:
Practice Address - Street 1:92 LINDA VISTA ST
Practice Address - Street 2:
Practice Address - City:BENICIA
Practice Address - State:CA
Practice Address - Zip Code:94510-2231
Practice Address - Country:US
Practice Address - Phone:510-410-1892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT4222225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant