Provider Demographics
NPI:1669741724
Name:LARSEN, JAMES ROBERT JR (ATC LAT)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:ROBERT
Last Name:LARSEN
Suffix:JR
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 1:387 N FERRIS ST
Mailing Address - Street 2:APT L
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-2042
Mailing Address - Country:US
Mailing Address - Phone:307-359-0617
Mailing Address - Fax:
Practice Address - Street 1:387 N FERRIS ST
Practice Address - Street 2:APT L
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-2042
Practice Address - Country:US
Practice Address - Phone:307-359-0617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY0112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer