Provider Demographics
NPI:1043394216
Name:YARCZOWER, LARISA ALEXEYEVNA (PA-C)
Entity type:Individual
Prefix:
First Name:LARISA
Middle Name:ALEXEYEVNA
Last Name:YARCZOWER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LARISA
Other - Middle Name:ALEXEYEVNA
Other - Last Name:PAVLENKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:1000 E. MOUNTAIN DRIVE
Practice Address - Street 2:
Practice Address - City:WILKES-BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702
Practice Address - Country:US
Practice Address - Phone:570-820-6150
Practice Address - Fax:570-342-3316
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003388L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P24006Medicare UPIN
PAP24006Medicare UPIN
164473F6CMedicare UPIN
PA045288Medicare PIN