Provider Demographics
NPI:1386659688
Name:LARSON, PAMELA TERRILL (PT)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:TERRILL
Last Name:LARSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 ALBERT CREE DR
Mailing Address - Street 2:VERMONT SPORTS MEDICINE CENTER
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701
Mailing Address - Country:US
Mailing Address - Phone:802-775-1300
Mailing Address - Fax:802-773-9300
Practice Address - Street 1:5 ALBERT CREE DR
Practice Address - Street 2:VERMONT SPORTS MEDICINE CENTER
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701
Practice Address - Country:US
Practice Address - Phone:802-775-1300
Practice Address - Fax:802-773-9300
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2010-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0400000988225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT00009577OtherBCBS
VTOVN2169Medicaid
43428OtherMVP
4416927OtherAETNA
VN2169Medicare ID - Type Unspecified
VTOVN2169Medicaid
VTUX9385Medicare PIN