MEDICARE: EVAN LARSON

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	332B00000X	Durable Medical Equipment & Medical Supplies	1001565	TX

General Provider Information

NPI Number	:	1376164921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVAN LARSON

Provider Business Mailing Address
First Line	:	1100 BRIDGEWOOD DR STE 102
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-0808
Country	:	US
Telephone Number	:	817-966-7000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1100 BRIDGEWOOD DR STE 102
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76112-0808
Country	:	US
Telephone Number	:	817-966-7000
Fax Number	:

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

Provider Enumeration Date	:	05/05/2020
Last Update Date	:	05/05/2020

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Directions to “ EVAN LARSON ” Practice Location

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