Provider Demographics
NPI:1578954855
Name:LARSEN, TISHA MARIE
Entity Type:Individual
Prefix:
First Name:TISHA
Middle Name:MARIE
Last Name:LARSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TISHA
Other - Middle Name:
Other - Last Name:LARSEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PMHNP, FNP
Mailing Address - Street 1:PO BOX 1121
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0254
Mailing Address - Country:US
Mailing Address - Phone:541-672-2691
Mailing Address - Fax:
Practice Address - Street 1:621 W MADRONE ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-3090
Practice Address - Country:US
Practice Address - Phone:541-440-3500
Practice Address - Fax:541-957-3003
Is Sole Proprietor?:No
Enumeration Date:2015-02-09
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201500780NP-PP363LF0000X
OR201910861NP-PP163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR165772Medicaid