Provider Demographics
NPI:1528013307
Name:MUSGRAVE, LARISSA A (LRD)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:A
Last Name:MUSGRAVE
Suffix:
Gender:F
Credentials:LRD
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 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-253-5300
Mailing Address - Fax:701-253-5402
Practice Address - Street 1:401 3RD ST SE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-4247
Practice Address - Country:US
Practice Address - Phone:701-253-5300
Practice Address - Fax:701-253-5402
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND626133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54497Medicaid
ND6300193OtherMEDICA
ND6300192OtherMEDICA #
NDP00054456OtherRR MEDICARE#
NDHP38430OtherHEALTHPARTNERS #
ND6300193OtherMEDICA
ND54497Medicaid
ND713142Medicare PIN