Provider Demographics
NPI:1174500425
Name:HELLGREN, LARISA K (PAC)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:K
Last Name:HELLGREN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2019
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:TN
Mailing Address - Zip Code:37116-2019
Mailing Address - Country:US
Mailing Address - Phone:615-860-8822
Mailing Address - Fax:615-865-7598
Practice Address - Street 1:355 NEW SHACKLE ISLAND RD
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:TN
Practice Address - Zip Code:37075-2479
Practice Address - Country:US
Practice Address - Phone:615-338-1258
Practice Address - Fax:615-338-1251
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051170363A00000X
TN1572363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P80976Medicare UPIN
067309Medicare ID - Type Unspecified