Provider Demographics
NPI:1366899940
Name:LARA, NATHANIEL EDWARD (PA)
Entity type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:EDWARD
Last Name:LARA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93638-3631
Mailing Address - Country:US
Mailing Address - Phone:559-664-4000
Mailing Address - Fax:
Practice Address - Street 1:344 E 6TH ST
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93638-3631
Practice Address - Country:US
Practice Address - Phone:559-664-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53394363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical