Healthcare Provider Details

I. General information

NPI: 1174828685
Provider Name (Legal Business Name): AARON JAY LARSON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2011
Last Update Date: 10/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E 6TH PL
MESA AZ
85201-5068
US

IV. Provider business mailing address

7740 LISBON RD
MORRIS IL
60450-7615
US

V. Phone/Fax

Practice location:
  • Phone: 480-668-0500
  • Fax:
Mailing address:
  • Phone: 815-685-9833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0904
License Number StateAZ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: