Provider Demographics
NPI:1225337132
Name:RUN, LARISSA IVANOVNA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LARISSA
Middle Name:IVANOVNA
Last Name:RUN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:LARISSA
Other - Middle Name:IVANOVNA
Other - Last Name:RUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9701 WEST FLAMINGO RD
Mailing Address - Street 2:#4
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147
Mailing Address - Country:US
Mailing Address - Phone:702-240-3929
Mailing Address - Fax:702-240-4203
Practice Address - Street 1:9701 WEST FLAMINGO RD
Practice Address - Street 2:#4
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89147
Practice Address - Country:US
Practice Address - Phone:702-240-3929
Practice Address - Fax:702-240-4203
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-17
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1268363A00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No174400000XOther Service ProvidersSpecialist