Provider Demographics
NPI:1326396284
Name:FOPEANO, LARISSA MAGNESS (PA)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:MAGNESS
Last Name:FOPEANO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-6000
Mailing Address - Fax:
Practice Address - Street 1:1291 BOSTON POST RD STE 105
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-3476
Practice Address - Country:US
Practice Address - Phone:860-358-5100
Practice Address - Fax:860-358-8655
Is Sole Proprietor?:No
Enumeration Date:2012-08-27
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003036363A00000X
NY015899363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant