MEDICARE: MATTHEW LUKE LARSON MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT017074	PA

General Provider Information

NPI Number	:	1033190368
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW LUKE LARSON MPT

Provider Business Mailing Address
First Line	:	495 MATTHEW ST
Second Line	:
City	:	UNIVERSAL CITY
State	:	TX
Zip	:	78148-4609
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9708 BELAIR RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21236-1108
Country	:	US
Telephone Number	:	877-407-3422
Fax Number	:	877-407-4329

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/14/2005
Last Update Date	:	04/23/2025

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