Provider Demographics
NPI:1619309135
Name:HATALA, LARISSA MARIA (DPM)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:MARIA
Last Name:HATALA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-474-4770
Mailing Address - Fax:336-474-4779
Practice Address - Street 1:211 OLD LEXINGTON RD
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:NC
Practice Address - Zip Code:27360-3428
Practice Address - Country:US
Practice Address - Phone:336-474-4770
Practice Address - Fax:336-474-4779
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006469213E00000X
NC632213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist