Healthcare Provider Details

I. General information

NPI: 1376248740
Provider Name (Legal Business Name): MARCO NELSON LARSON DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2023
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 S IDAHO RD STE 210
APACHE JUNCTION AZ
85119-6405
US

IV. Provider business mailing address

455 TOLL GATE RD
WARWICK RI
02886-2759
US

V. Phone/Fax

Practice location:
  • Phone: 480-983-0877
  • Fax: 480-983-3172
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number26653
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberLPT-033894
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: