MEDICARE: LARISA URIEVNA WILSON

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	3747A0650X	Attendant Care Provider
2	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1396245007
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARISA URIEVNA WILSON

Provider Business Mailing Address
First Line	:	5578 VICTORIA REGINA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-7490
Country	:	US
Telephone Number	:	702-240-3800
Fax Number	:

Provider Business Practice Location Address
First Line	:	5578 VICTORIA REGINA AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89139-7490
Country	:	US
Telephone Number	:	702-240-3800
Fax Number	:

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

Provider Enumeration Date	:	02/19/2018
Last Update Date	:	02/19/2018

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