Provider Demographics
NPI:1386668572
Name:JOHNSON, LARA ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:ELIZABETH
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13203 LADYBANK LN
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20171-4031
Mailing Address - Country:US
Mailing Address - Phone:580-251-0082
Mailing Address - Fax:
Practice Address - Street 1:13203 LADYBANK LN
Practice Address - Street 2:
Practice Address - City:HERNDON
Practice Address - State:VA
Practice Address - Zip Code:20171-4031
Practice Address - Country:US
Practice Address - Phone:580-251-0082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05335363A00000X
AK667363A00000X
VA110003747363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKQ35185Medicare UPIN
TX8K0328Medicare PIN
AK8EC290Medicare PIN
TX8K0326Medicare PIN