Provider Demographics
NPI:1902110232
Name:BEYERLEIN, LARISSA (MD)
Entity Type:Individual
Prefix:MS
First Name:LARISSA
Middle Name:
Last Name:BEYERLEIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 CHIPETA WAY, SUITE 200
Mailing Address - Street 2:PEDIATRIC EMERGENCY MEDICINE
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84158
Mailing Address - Country:US
Mailing Address - Phone:801-587-7436
Mailing Address - Fax:801-587-7455
Practice Address - Street 1:295 CHIPETA WAY
Practice Address - Street 2:DEPARTMENT OF PEDIATRIC EMERGENCY MEDICINE
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84158
Practice Address - Country:US
Practice Address - Phone:801-587-7436
Practice Address - Fax:801-587-7455
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT8637381-12052080P0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine