Basic Information
| Provider Information | |||||||||
| NPI: | 1023370780 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOHLER | ||||||||
| FirstName: | LARISSA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 E BROADWAY AVE | ||||||||
| Address2: | |||||||||
| City: | BISMARCK | ||||||||
| State: | ND | ||||||||
| PostalCode: | 585014520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015307000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2615 FAIRWAY ST | ||||||||
| Address2: | |||||||||
| City: | DICKINSON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 58601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7014566000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2012 | ||||||||
| LastUpdateDate: | 07/12/2018 | ||||||||
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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 | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 133V00000X | 865 | ND | N | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.