Basic Information
| Provider Information | |||||||||
| NPI: | 1053844811 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FLORES | ||||||||
| FirstName: | LARISSA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3815 E BELL RD STE 2200 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850322139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026333838 | ||||||||
| FaxNumber: | 6026333841 | ||||||||
| Practice Location | |||||||||
| Address1: | 10815 W MCDOWELL RD STE 305 | ||||||||
| Address2: | |||||||||
| City: | AVONDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853925016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239363312 | ||||||||
| FaxNumber: | 6239364248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2017 | ||||||||
| LastUpdateDate: | 06/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SF0001X | AP9917 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health |
ID Information
| ID | Type | State | Issuer | Description | Z201263 | 01 | AZ | MEDICARE | OTHER | 257668 | 05 | AZ | MEDICAID |