Provider Demographics
NPI:1093099855
Name:ANTHONY, LARISSA NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:NICOLE
Last Name:ANTHONY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:LARISSA
Other - Middle Name:NICOLE
Other - Last Name:BOISSELLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5151 E BROADWAY RD STE 107
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-1346
Mailing Address - Country:US
Mailing Address - Phone:480-290-7000
Mailing Address - Fax:602-254-6840
Practice Address - Street 1:2550 W UNION HILLS DR STE 390
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-5197
Practice Address - Country:US
Practice Address - Phone:602-443-4068
Practice Address - Fax:623-434-8310
Is Sole Proprietor?:No
Enumeration Date:2011-09-28
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4993363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ339667Medicaid
AZ4993OtherLICENSE