Provider Demographics
NPI:1033679584
Name:ASSAM, LARISSA (MD)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:ASSAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4151 BLADENSBURG RD
Mailing Address - Street 2:
Mailing Address - City:COLMAR MANOR
Mailing Address - State:MD
Mailing Address - Zip Code:20722-1928
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4151 BLADENSBURG RD
Practice Address - Street 2:
Practice Address - City:COLMAR MANOR
Practice Address - State:MD
Practice Address - Zip Code:20722-1928
Practice Address - Country:US
Practice Address - Phone:301-699-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program