=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093998650
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHERWIN LARRACAS PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2007
-----------------------------------------------------
Last Update Date | 12/06/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 BARTON CREEK BLVD
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78735-1603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-610-9401
-----------------------------------------------------
Fax | 512-329-3282
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8721 FOGGY MOUNTAIN DR
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78736-3370
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-301-3103
-----------------------------------------------------
Fax | 512-301-3103
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1121242
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2251G0304X
-----------------------------------------------------
Taxonomy Name | Geriatric Physical Therapist
-----------------------------------------------------
License Number | 1121242
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------