Provider Demographics
NPI:1174155519
Name:LARSEN, TAMARA LYNN (PT)
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:LYNN
Last Name:LARSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:LYNN
Other - Last Name:WATKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:820 VILLAGE WAY
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-4612
Mailing Address - Country:US
Mailing Address - Phone:952-927-2960
Mailing Address - Fax:952-927-2961
Practice Address - Street 1:820 VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-4612
Practice Address - Country:US
Practice Address - Phone:952-927-2960
Practice Address - Fax:952-927-2961
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6074225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist