Healthcare Provider Details

I. General information

NPI: 1922247345
Provider Name (Legal Business Name): LARISSA TIAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2009
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4320 SEMINARY RD
ALEXANDRIA VA
22304-1535
US

IV. Provider business mailing address

3300 GALLOWS RD
FALLS CHURCH VA
22042-3300
US

V. Phone/Fax

Practice location:
  • Phone: 703-504-3000
  • Fax: 703-504-3388
Mailing address:
  • Phone: 703-776-4011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5526
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110006747
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: