Provider Demographics
NPI:1588268288
Name:LARA PIERCE, MD PLLC
Entity type:Organization
Organization Name:LARA PIERCE, MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JAYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:WYNNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-631-9601
Mailing Address - Street 1:217 W BELKNAP ST
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:76458-2307
Mailing Address - Country:US
Mailing Address - Phone:940-567-8114
Mailing Address - Fax:940-521-5511
Practice Address - Street 1:217 W BELKNAP ST
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TX
Practice Address - Zip Code:76458-2307
Practice Address - Country:US
Practice Address - Phone:940-567-8114
Practice Address - Fax:940-521-5511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-24
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty