Healthcare Provider Details

I. General information

NPI: 1295319804
Provider Name (Legal Business Name): ETHAN LARSEN ATC, LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2021
Last Update Date: 05/10/2021
Certification Date: 05/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 300 W STE 410
PROVO UT
84604-3354
US

IV. Provider business mailing address

273 W 590 N
VINEYARD UT
84059-4812
US

V. Phone/Fax

Practice location:
  • Phone: 515-421-6223
  • Fax:
Mailing address:
  • Phone: 515-421-6223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number12298266-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: