Provider Demographics
NPI:1386644060
Name:FISHER, LARA LEE (MD)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:LEE
Last Name:FISHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4414 LAKE BOONE TRL
Mailing Address - Street 2:SUITE 405
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7513
Mailing Address - Country:US
Mailing Address - Phone:919-876-8225
Mailing Address - Fax:919-876-3371
Practice Address - Street 1:4414 LAKE BOONE TRL
Practice Address - Street 2:SUITE 405
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7513
Practice Address - Country:US
Practice Address - Phone:919-876-8225
Practice Address - Fax:919-876-3371
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891289TMedicaid
G91816Medicare UPIN
NC2292337AMedicare ID - Type Unspecified