Basic Information
| Provider Information | |||||||||
| NPI: | 1639793557 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GILLERN | ||||||||
| FirstName: | LARISA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 WOODLAND HILLS DR | ||||||||
| Address2: | |||||||||
| City: | TRUMBULL | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066116356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039794882 | ||||||||
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| Practice Location | |||||||||
| Address1: | 34 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | NORWALK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068503815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038522000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2020 | ||||||||
| LastUpdateDate: | 06/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.