Healthcare Provider Details

I. General information

NPI: 1023530342
Provider Name (Legal Business Name): OLIVIA MAE LARUSSA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2017
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 23RD ST NW
WASHINGTON DC
20037-2342
US

IV. Provider business mailing address

3811 FAIRFAX DR STE 1000
ARLINGTON VA
22203-1782
US

V. Phone/Fax

Practice location:
  • Phone: 202-741-3000
  • Fax:
Mailing address:
  • Phone: 202-741-3574
  • Fax: 202-741-3219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberTL2763
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2763
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA200001702
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: