Healthcare Provider Details

I. General information

NPI: 1093099855
Provider Name (Legal Business Name): LARISSA NICOLE ANTHONY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. LARISSA NICOLE BOISSELLE

II. Dates (important events)

Enumeration Date: 09/28/2011
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 W UNION HILLS DR STE 390
PHOENIX AZ
85027-5197
US

IV. Provider business mailing address

5151 E BROADWAY RD STE 107
MESA AZ
85206-1346
US

V. Phone/Fax

Practice location:
  • Phone: 602-443-4068
  • Fax: 623-434-8310
Mailing address:
  • Phone: 480-290-7000
  • Fax: 602-254-6840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4993
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: