Provider Demographics
NPI:1932634938
Name:BRUCK, LARISSA J (CRNA)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:J
Last Name:BRUCK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:J
Other - Last Name:YANNACCONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3340 N CENTER ST STE 800
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-7406
Mailing Address - Country:US
Mailing Address - Phone:801-990-1911
Mailing Address - Fax:
Practice Address - Street 1:3741 W 12600 S
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7215
Practice Address - Country:US
Practice Address - Phone:801-285-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-27
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP134258367500000X
UT12797278-8901367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX373380002OtherCSHCN
TX373380001Medicaid