Healthcare Provider Details

I. General information

NPI: 1659536480
Provider Name (Legal Business Name): LARISSA MARIA ALLEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 01/05/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6130 N LA CHOLLA BLVD SUITE 200
TUCSON AZ
85741-3557
US

IV. Provider business mailing address

6130 N LA CHOLLA BLVD SUITE 200
TUCSON AZ
85741-3557
US

V. Phone/Fax

Practice location:
  • Phone: 520-219-8342
  • Fax: 520-219-7117
Mailing address:
  • Phone: 520-219-8342
  • Fax: 520-219-7117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number48787
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberR70554
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: