Individual
ETHAN LARSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
ATC, LAT
Contact information
Practice address
1055 N 300 W STE 410, PROVO, UT 84604-3354
(515) 421-6223
Mailing address
273 W 590 N, VINEYARD, UT 84059-4812
(515) 421-6223
Taxonomy
Speciality
Code
Description
License number
State
204C00000X
Sports Medicine (Neuromusculoskeletal Medicine) Physician
Primary
12298266-4810
UT
Other
Enumeration date
05/10/2021
Last updated
05/10/2021
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