Provider Demographics
NPI:1386647261
Name:KAHLE, LARISSA MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LARISSA
Middle Name:MARIE
Last Name:KAHLE
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 1:5583 JAMIES OAK DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45248-1067
Mailing Address - Country:US
Mailing Address - Phone:513-574-4445
Mailing Address - Fax:
Practice Address - Street 1:10500 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45242-4402
Practice Address - Country:US
Practice Address - Phone:513-745-1307
Practice Address - Fax:513-745-1444
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA839363AM0700X
OH50-00-2067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
0551830Medicare ID - Type Unspecified
Q34284Medicare UPIN