Provider Demographics
NPI:1205315108
Name:LARSON, MATTHEW (DPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
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 1:7551 9TH ST N STE 100
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-6632
Mailing Address - Country:US
Mailing Address - Phone:651-747-4328
Mailing Address - Fax:
Practice Address - Street 1:433 MENDOTA RD E
Practice Address - Street 2:
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-5104
Practice Address - Country:US
Practice Address - Phone:763-957-7750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-10
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11283225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist