Provider Demographics
NPI:1962755611
Name:LUCERO, LARAH (PA-C)
Entity type:Individual
Prefix:
First Name:LARAH
Middle Name:
Last Name:LUCERO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 UNIVERSITY LN
Mailing Address - Street 2:APT 1508
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32922-6556
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10931 DYLAN LOREN CIR
Practice Address - Street 2:SUITE A
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-4449
Practice Address - Country:US
Practice Address - Phone:407-218-4444
Practice Address - Fax:321-284-1514
Is Sole Proprietor?:No
Enumeration Date:2012-10-18
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106934363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant