Provider Demographics
NPI:1023530342
Name:LARUSSA, OLIVIA MAE (PA-C)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:MAE
Last Name:LARUSSA
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 1:3811 FAIRFAX DR STE 1000
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22203-1782
Mailing Address - Country:US
Mailing Address - Phone:202-741-3574
Mailing Address - Fax:202-741-3219
Practice Address - Street 1:900 23RD ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-2342
Practice Address - Country:US
Practice Address - Phone:202-741-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL2763207XX0005X
SC2763363AS0400X
DCPA200001702363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3448PAMedicaid