Provider Demographics
NPI:1730299645
Name:REVZINA, LARISA M (FNP)
Entity Type:Individual
Prefix:
First Name:LARISA
Middle Name:M
Last Name:REVZINA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1631 HOLT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-6929
Mailing Address - Country:US
Mailing Address - Phone:650-940-9686
Mailing Address - Fax:
Practice Address - Street 1:225 SAN ANTONIO RD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-1209
Practice Address - Country:US
Practice Address - Phone:650-948-0804
Practice Address - Fax:650-948-3319
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN555478363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily