Provider Demographics
NPI:1952709982
Name:BOWER, LARISSA ANN (CRNP)
Entity Type:Individual
Prefix:
First Name:LARISSA
Middle Name:ANN
Last Name:BOWER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:LARISSA
Other - Middle Name:ANN
Other - Last Name:EAKIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:2901 JOLLY RD
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH MEETING
Mailing Address - State:PA
Mailing Address - Zip Code:19462-2324
Mailing Address - Country:US
Mailing Address - Phone:610-272-8221
Mailing Address - Fax:
Practice Address - Street 1:2901 JOLLY RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH MEETING
Practice Address - State:PA
Practice Address - Zip Code:19462-2324
Practice Address - Country:US
Practice Address - Phone:610-272-8221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-08
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP014545363LA2200X, 363LG0600X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103036860Medicaid