Provider Demographics
NPI:1205364833
Name:LARA, GISELLE (CAA)
Entity Type:Individual
Prefix:
First Name:GISELLE
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 CRYSTAL DR APT 323
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22202-4103
Mailing Address - Country:US
Mailing Address - Phone:815-566-6762
Mailing Address - Fax:
Practice Address - Street 1:110 IRVING ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-3017
Practice Address - Country:US
Practice Address - Phone:855-546-1686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-26
Last Update Date:2017-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant