MEDICARE: CHARLOTTE LARISSA COUCH PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	5482	TN

General Provider Information

NPI Number	:	1245014745
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLOTTE LARISSA COUCH PA

Provider Business Mailing Address
First Line	:	6584 POPLAR AVE STE 212
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38138-3687
Country	:	US
Telephone Number	:	662-883-4198
Fax Number	:	662-883-4198

Provider Business Practice Location Address
First Line	:	6584 POPLAR AVE STE 212
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38138-3687
Country	:	US
Telephone Number	:	662-883-4198
Fax Number	:	662-883-4198

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2023
Last Update Date	:	02/07/2026

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