Provider Demographics
NPI:1841417573
Name:MARKEVICH, LARISSA (NP)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:MARKEVICH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2170 CENTURY PARK E
Mailing Address - Street 2:SUITE 1506
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90067-2243
Mailing Address - Country:US
Mailing Address - Phone:213-590-3480
Mailing Address - Fax:310-286-1090
Practice Address - Street 1:2170 CENTURY PARK E
Practice Address - Street 2:SUITE 1506
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90067-2243
Practice Address - Country:US
Practice Address - Phone:213-590-3480
Practice Address - Fax:310-286-1090
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13502363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN502860OtherRN CERTIFICATE
CA13502OtherCALIFORNIA LISENCE
CAQ20179Medicare UPIN
CARN502860OtherRN CERTIFICATE