Provider Demographics
NPI:1396245007
Name:WILSON, LARISA URIEVNA
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:URIEVNA
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5578 VICTORIA REGINA AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89139-7490
Mailing Address - Country:US
Mailing Address - Phone:702-240-3800
Mailing Address - Fax:
Practice Address - Street 1:5578 VICTORIA REGINA AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89139-7490
Practice Address - Country:US
Practice Address - Phone:702-240-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider