Provider Demographics
NPI:1487096947
Name:GARTH, LARISSA L (PA-C)
Entity type:Individual
Prefix:
First Name:LARISSA
Middle Name:L
Last Name:GARTH
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:4132 TURNING LEAF DR
Mailing Address - Street 2:
Mailing Address - City:NOLANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76559-0040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2719 S EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-3354
Practice Address - Country:US
Practice Address - Phone:949-484-9517
Practice Address - Fax:949-569-1295
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2025-03-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAPA-61580095363A00000X
PAMA066148363A00000X
CA63771363A00000X
TXPA10409363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant