Provider Demographics
NPI:1679056147
Name:WILEY, LARISSA DOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:DOHN
Last Name:WILEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:MARIE
Other - Last Name:DOHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDH
Mailing Address - Street 1:7500 N DREAMY DRAW DR STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4668
Mailing Address - Country:US
Mailing Address - Phone:480-882-4545
Mailing Address - Fax:480-882-5814
Practice Address - Street 1:8705 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85257-3909
Practice Address - Country:US
Practice Address - Phone:480-882-4545
Practice Address - Fax:480-946-6997
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-11
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7140363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ435328Medicaid