Provider Demographics
NPI:1366687709
Name:POLES, LARISSA JEAN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LARISSA
Middle Name:JEAN
Last Name:POLES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:579 VIA DEL CABALLO
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-8911
Mailing Address - Country:US
Mailing Address - Phone:760-212-2792
Mailing Address - Fax:
Practice Address - Street 1:3930 4TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3119
Practice Address - Country:US
Practice Address - Phone:619-297-9610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-15
Last Update Date:2010-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20111363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant