Provider Demographics
NPI:1366949455
Name:LARSON, NATHAN (MS, AT, ATC)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:MS, AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 MACINNES DR STE 201
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:49931-1144
Mailing Address - Country:US
Mailing Address - Phone:906-487-7532
Mailing Address - Fax:906-487-7527
Practice Address - Street 1:601 QUINCY ST.
Practice Address - Street 2:ATHLETICS / PAAVO NURMI GYM
Practice Address - City:HANCOCK
Practice Address - State:MI
Practice Address - Zip Code:49930-4993
Practice Address - Country:US
Practice Address - Phone:906-487-7532
Practice Address - Fax:906-487-7527
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010002092083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2601000209OtherSTATE LICENSURE