Healthcare Provider Details

I. General information

NPI: 1700967908
Provider Name (Legal Business Name): MRS. LARISA ANATOLYEVNA LYSAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4815 WATT AVE
NORTH HIGHLANDS CA
95660-5108
US

IV. Provider business mailing address

1860 HOWE AVE STE 440
SACRAMENTO CA
95825-1098
US

V. Phone/Fax

Practice location:
  • Phone: 855-354-2242
  • Fax:
Mailing address:
  • Phone: 916-569-8484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number16740
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: