Provider Demographics
NPI:1780158121
Name:ROBERTS, LARISSA J (LAT, ATC, MED)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:J
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LAT, ATC, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:356 MCGOUGH WAY
Mailing Address - Street 2:
Mailing Address - City:TRAFFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15085-1608
Mailing Address - Country:US
Mailing Address - Phone:814-227-6720
Mailing Address - Fax:
Practice Address - Street 1:410 PELLIS RD
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-4700
Practice Address - Country:US
Practice Address - Phone:814-227-6720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0065732083S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports MedicineGroup - Single Specialty