Ethan Larsen, ATC, LAT

Primary specialty

Sports Medicine (Neuromusculoskeletal Medicine) PhysicianTaxonomy code 204C00000X

License

12298266-4810 Issued in UT

Practice address

1055 N 300 W Ste 410
Provo, UT 84604-3354

Phone

(515) 421-6223

NPI assigned

May 10, 2021

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1620604800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1620604800000",
    "number": "1295319804",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "273 W 590 N",
            "city": "VINEYARD",
            "state": "UT",
            "postal_code": "840594812",
            "telephone_number": "515-421-6223"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1055 N 300 W STE 410",
            "city": "PROVO",
            "state": "UT",
            "postal_code": "846043354",
            "telephone_number": "515-421-6223"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "LARSEN",
        "first_name": "ETHAN",
        "credential": "ATC, LAT",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2021-05-10",
        "last_updated": "2021-05-10",
        "certification_date": "2021-05-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "204C00000X",
            "taxonomy_group": "",
            "desc": "Neuromusculoskeletal Medicine, Sports Medicine",
            "state": "UT",
            "license": "12298266-4810",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Ashley Kristen Larsen, CSW
• Bryn Larsen
• Darby Larsen, DPT
• Devery Larsen, SLP
• Elizabeth Ann Larsen, APRN
• Jeremy Larsen
• Jill J Larsen, RN
• Jonathan David Larsen
• Kevin Leander Larsen, RPH
• Steven F Larsen, NP

• Sports Medicine (Neuromusculoskeletal Medicine) Physician in Provo, UT
• Providers in Provo, UT by specialty
• Sports Medicine (Neuromusculoskeletal Medicine) Physician in Utah

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 10, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.