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 1:4359 NEW SHEPHERDSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-8000
Mailing Address - Country:US
Mailing Address - Phone:502-350-5400
Mailing Address - Fax:502-350-5406
Practice Address - Street 1:4359 NEW SHEPHERDSVILLE RD
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-8000
Practice Address - Country:US
Practice Address - Phone:859-278-1316
Practice Address - Fax:859-276-3847
Is Sole Proprietor?:No
Enumeration Date:2014-05-27
Last Update Date:2021-06-08
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