Provider Demographics
NPI:1255666020
Name:ACKERSON, LARISSA M (DO)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:M
Last Name:ACKERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:ISU THIELEN STUDENT HEALTH CENTER 2647 UNION DRIVE
Mailing Address - Street 2:
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50011-0001
Mailing Address - Country:US
Mailing Address - Phone:515-294-5801
Mailing Address - Fax:515-294-1190
Practice Address - Street 1:ISU THIELEN STUDENT HEALTH CENTER 2647 UNION DRIVE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50011
Practice Address - Country:US
Practice Address - Phone:515-294-5801
Practice Address - Fax:515-294-1190
Is Sole Proprietor?:No
Enumeration Date:2009-10-12
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA04259207Q00000X
WI54965207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA04259OtherIA LICENSE
WI54965OtherLICENSE