Provider Demographics
NPI:1063185577
Name:LARA, EDGAR MOISES
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:MOISES
Last Name:LARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 BEALE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94105-1813
Mailing Address - Country:US
Mailing Address - Phone:415-615-5103
Mailing Address - Fax:415-615-5303
Practice Address - Street 1:50 BEALE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94105-1813
Practice Address - Country:US
Practice Address - Phone:415-615-5103
Practice Address - Fax:415-615-5303
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator