Provider Demographics
NPI:1811461106
Name:GONZALEZ, LARISSA M (PA-C)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:M
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 E 17TH ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-2641
Mailing Address - Country:US
Mailing Address - Phone:714-352-2911
Mailing Address - Fax:714-380-6235
Practice Address - Street 1:1206 E 17TH ST STE 101
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-2641
Practice Address - Country:US
Practice Address - Phone:714-352-2911
Practice Address - Fax:714-380-6235
Is Sole Proprietor?:No
Enumeration Date:2019-01-20
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56383363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant