Provider Demographics
NPI:1639793557
Name:GILLERN, LARISA ANN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:LARISA
Middle Name:ANN
Last Name:GILLERN
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
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Mailing Address - Street 1:105 WOODLAND HILLS DR
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-6356
Mailing Address - Country:US
Mailing Address - Phone:203-979-4882
Mailing Address - Fax:
Practice Address - Street 1:34 MAPLE ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-3815
Practice Address - Country:US
Practice Address - Phone:203-852-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-05
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical