Provider Demographics
NPI:1093564932
Name:UMBERGER, LARISSA (PA-S3)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:
Last Name:UMBERGER
Suffix:
Gender:F
Credentials:PA-S3
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 529
Mailing Address - Street 2:
Mailing Address - City:OLATHE
Mailing Address - State:CO
Mailing Address - Zip Code:81425-0529
Mailing Address - Country:US
Mailing Address - Phone:703-236-1419
Mailing Address - Fax:
Practice Address - Street 1:1250 VALLEY VIEW DR
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-3138
Practice Address - Country:US
Practice Address - Phone:970-874-8981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2025-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0009312363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant