Provider Demographics
NPI:1205282951
Name:LAROSE, MEGHAN ALYSSA (PA-C)
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:ALYSSA
Last Name:LAROSE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MEGHAN
Other - Middle Name:ALYSSA
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:38135 MARKET SQ
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33542-7505
Mailing Address - Country:US
Mailing Address - Phone:813-528-4975
Mailing Address - Fax:
Practice Address - Street 1:10004 N DALE MABRY HWY
Practice Address - Street 2:SUITE 101
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-4494
Practice Address - Country:US
Practice Address - Phone:813-931-3999
Practice Address - Fax:813-936-7147
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109489363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6W1ULOtherBC/BS FLORIDA BLUE
FL6W1ULOtherBC/BS FLORIDA BLUE