Basic Information
| Provider Information | |||||||||
| NPI: | 1710377148 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPATKO | ||||||||
| FirstName: | LARISA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 872104 | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852872104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4808841935 | ||||||||
| FaxNumber: | 4807273065 | ||||||||
| Practice Location | |||||||||
| Address1: | 451 E UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | TEMPE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852815391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809653346 | ||||||||
| FaxNumber: | 4809656531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2015 | ||||||||
| LastUpdateDate: | 10/11/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP5701 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 928722 | 05 | AZ | MEDICAID |