Healthcare Provider Details

I. General information

NPI: 1548182397
Provider Name (Legal Business Name): MOIRA MCCOLLAM-LARSON LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2026
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3415 PETERS AVE
SIOUX CITY IA
51106-2203
US

IV. Provider business mailing address

3800 GLEN ELLEN RD UNIT 433
SIOUX CITY IA
51106-8034
US

V. Phone/Fax

Practice location:
  • Phone: 605-681-4851
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number130953
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: