Provider Demographics
NPI:1114339173
Name:WOOD, LARA L (PA-C)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:L
Last Name:WOOD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:LEE
Other - Last Name:BRADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3810 SPRINGHURST BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-6162
Mailing Address - Country:US
Mailing Address - Phone:502-583-1749
Mailing Address - Fax:
Practice Address - Street 1:3810 SPRINGHURST BLVD STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-6162
Practice Address - Country:US
Practice Address - Phone:502-583-1749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-27
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2196363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100447620Medicaid
VA1114339173OtherTRICARE