Provider Demographics
NPI:1073750675
Name:BOUVE, LARA R (FNP - BC)
Entity Type:Individual
Prefix:MRS
First Name:LARA
Middle Name:R
Last Name:BOUVE
Suffix:
Gender:F
Credentials:FNP - BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4060 4TH AVE
Mailing Address - Street 2:SUITE 505
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2116
Mailing Address - Country:US
Mailing Address - Phone:619-298-1318
Mailing Address - Fax:619-298-0843
Practice Address - Street 1:4060 4TH AVE
Practice Address - Street 2:SUITE 505
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2116
Practice Address - Country:US
Practice Address - Phone:619-298-1318
Practice Address - Fax:619-298-0843
Is Sole Proprietor?:No
Enumeration Date:2009-01-19
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5985363LF0000X
FL2222592363LF0000X
TN6980363LF0000X
CA20664363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFS452ZMedicare PIN
COCO304643Medicare PIN