=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427148014
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARISA B. YAROSHCHUK MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2006
-----------------------------------------------------
Last Update Date | 12/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7495 S STATE ST
-----------------------------------------------------
City | MIDVALE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84047-2013
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-213-9400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 510004
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84151-0004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-213-9400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 5316510-1205
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------