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General NPI Number Information
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NPI Number | 1194948232
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Entity Type | Individual
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Provider Name | JASON JOSEPH LARSON M.ED., ATC, EMT
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Gender | Male
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Dates
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Enumeration Date | 04/10/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2500 MAIN ST
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City | LAWRENCEVILLE
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State | NJ
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Zip | 08648-1600
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Country | US
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Telephone | 609-895-2037
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Fax | 609-620-7634
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Provider Business Mailing Address
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Address Line | PO BOX 6562
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City | LAWRENCEVILLE
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State | NJ
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Zip | 08648-0562
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Country | US
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Telephone | 609-620-7606
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Fax | 609-620-7634
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 25MT00097100
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License Number State | NJ
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