Provider Demographics
NPI:1083008940
Name:LARA, KELLY ANDREW
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANDREW
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:PO BOX 689022
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-9022
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10120 E OLD VAIL RD STE 100
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85747-9414
Practice Address - Country:US
Practice Address - Phone:520-989-8012
Practice Address - Fax:520-989-8014
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA148544208600000X
AZ64112208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery