Provider Demographics
NPI:1710473764
Name:HAUG, LARISSA ANN (PA)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:ANN
Last Name:HAUG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:ANN
Other - Last Name:RECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4 N PARK ST
Mailing Address - Street 2:
Mailing Address - City:NORTHWOOD
Mailing Address - State:ND
Mailing Address - Zip Code:58267-4102
Mailing Address - Country:US
Mailing Address - Phone:701-587-6900
Mailing Address - Fax:701-587-6109
Practice Address - Street 1:4 N PARK ST
Practice Address - Street 2:
Practice Address - City:NORTHWOOD
Practice Address - State:ND
Practice Address - Zip Code:58267-4102
Practice Address - Country:US
Practice Address - Phone:701-587-6900
Practice Address - Fax:701-587-6109
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0729363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant