Healthcare Provider Details

I. General information

NPI: 1972103885
Provider Name (Legal Business Name): RYAN JAMES LARSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/29/2020
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 HADLEY RD STE 105
MOORESVILLE IN
46158-1884
US

IV. Provider business mailing address

823 ELMWOOD CIR
NOBLESVILLE IN
46062-8541
US

V. Phone/Fax

Practice location:
  • Phone: 317-834-5777
  • Fax:
Mailing address:
  • Phone: 801-664-7475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number07001458A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: