Provider Demographics
NPI:1295319804
Name:LARSEN, ETHAN (ATC, LAT)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:LARSEN
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 W 590 N
Mailing Address - Street 2:
Mailing Address - City:VINEYARD
Mailing Address - State:UT
Mailing Address - Zip Code:84059-4812
Mailing Address - Country:US
Mailing Address - Phone:515-421-6223
Mailing Address - Fax:
Practice Address - Street 1:1055 N 300 W STE 410
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3354
Practice Address - Country:US
Practice Address - Phone:515-421-6223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12298266-4810204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine