Provider Demographics
NPI:1154499192
Name:TAYLOR, LARISA (MD)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:
Last Name:TAYLOR
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 1:5610 SCOTTS VALLEY DR
Mailing Address - Street 2:B221
Mailing Address - City:SCOTTS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95066-3473
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1661 SOQUEL DR
Practice Address - Street 2:SUITE A
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1709
Practice Address - Country:US
Practice Address - Phone:831-476-7676
Practice Address - Fax:831-476-4824
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80736207V00000X
CABT8050255207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
BT8050255OtherLIC
CA00G358690Medicaid
A80736OtherDEA
00G358690Medicare ID - Type Unspecified
BT8050255OtherLIC