Provider Demographics
NPI:1720344393
Name:THOMAS, LARISSA ANN (MD)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:ANN
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1517
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-0410
Mailing Address - Country:US
Mailing Address - Phone:877-708-1119
Mailing Address - Fax:541-278-8349
Practice Address - Street 1:2011 4TH ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-2511
Practice Address - Country:US
Practice Address - Phone:541-963-4139
Practice Address - Fax:541-429-6661
Is Sole Proprietor?:No
Enumeration Date:2012-04-07
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD168475207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
R184141OtherMEDICARE PTAN PART A
R184162OtherMEDICARE PTAN - PART B