Provider Demographics
NPI:1063714848
Name:HUNTER, LARA LOUISE (PA)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:LOUISE
Last Name:HUNTER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:LOUISE
Other - Last Name:PERMUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2500 E PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-9718
Mailing Address - Country:US
Mailing Address - Phone:970-493-0112
Mailing Address - Fax:970-493-0521
Practice Address - Street 1:1610 DRY CREEK DR
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80503-6405
Practice Address - Country:US
Practice Address - Phone:303-772-1600
Practice Address - Fax:970-493-0521
Is Sole Proprietor?:No
Enumeration Date:2010-11-30
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0005669363AS0400X, 363AS0400X
FLPA9105676363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL03104600Medicaid