Provider Demographics
NPI:1356663827
Name:MILLER, LARISSA KAYE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LARISSA
Middle Name:KAYE
Last Name:MILLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:LARISSA
Other - Middle Name:KAYE
Other - Last Name:CLEVELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11511 SHADOW CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7298
Mailing Address - Country:US
Mailing Address - Phone:713-442-4997
Mailing Address - Fax:
Practice Address - Street 1:17510 W GRAND PKWY S STE 220
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-2647
Practice Address - Country:US
Practice Address - Phone:281-201-1338
Practice Address - Fax:281-201-1353
Is Sole Proprietor?:No
Enumeration Date:2010-02-24
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA06352363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA06352OtherTEXAS MEDICAL BOARD
TX8224NVOtherBCBS - XCITE SURGICAL
TXTXB149935OtherMEDICARE EMPLOYER PTAN
TX8650NQOtherBCBS - UNIVERSAL SURGICAL ASSISTANTS INC
TXPA06352OtherTEXAS MEDICAL BOARD
TX8650NQOtherBCBS - UNIVERSAL SURGICAL ASSISTANTS
TX8651NQOtherBCBS
TX8HM768OtherBCBS - UNIVERSAL SURGICAL PARTNERS
TX8LH929OtherBCBS - BLUE STAR SURGICAL ASSISTANTS LLC