Provider Demographics
NPI:1750840161
Name:PEXTON, LARISSA
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:PEXTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 OAK HILL LN APT 1225
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78744-2240
Mailing Address - Country:US
Mailing Address - Phone:425-903-1405
Mailing Address - Fax:
Practice Address - Street 1:10802 GEMSBUCK LDG
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78245-2702
Practice Address - Country:US
Practice Address - Phone:425-903-1405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-15
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
TXAT80502255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer