Provider Demographics
NPI:1326548173
Name:HYDE, LARA BRADBURY
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:BRADBURY
Last Name:HYDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:
Other - Last Name:BRADBURY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1968 PEACHTREE ROAD NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1281
Mailing Address - Country:US
Mailing Address - Phone:770-801-2500
Mailing Address - Fax:
Practice Address - Street 1:1968 PEACHTREE RD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309
Practice Address - Country:US
Practice Address - Phone:404-605-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN272657363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care