Healthcare Provider Details

I. General information

NPI: 1386105278
Provider Name (Legal Business Name): LARISSA NKOUAMI PAMEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LARISSA NKOUAMI PAMEN

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 BREWSTER RD
BRISTOL CT
06010-5141
US

IV. Provider business mailing address

41 BREWSTER RD
BRISTOL CT
06010-5141
US

V. Phone/Fax

Practice location:
  • Phone: 860-585-3966
  • Fax:
Mailing address:
  • Phone: 860-585-3966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number82999
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MA12172800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: