Provider Demographics
NPI:1790091569
Name:WHITNEY, LARISSA DAWN (PA-C)
Entity Type:Individual
Prefix:DR
First Name:LARISSA
Middle Name:DAWN
Last Name:WHITNEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:DAWN
Other - Last Name:KRYDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:555 N DUKE ST FL 3
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17602-2250
Mailing Address - Country:US
Mailing Address - Phone:717-544-5945
Mailing Address - Fax:717-544-5944
Practice Address - Street 1:555 N DUKE ST FL 3
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602-2250
Practice Address - Country:US
Practice Address - Phone:717-544-5945
Practice Address - Fax:717-544-5944
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054514363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAKR192888Medicare PIN