Provider Demographics
NPI:1457463242
Name:LINGWALL-OVERSTREET, LARA CHRISTINE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LARA
Middle Name:CHRISTINE
Last Name:LINGWALL-OVERSTREET
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:LARA
Other - Middle Name:CHRISTINE
Other - Last Name:LINGWALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2100 POWELL ST
Mailing Address - Street 2:SUITE 900
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1826
Mailing Address - Country:US
Mailing Address - Phone:510-350-2600
Mailing Address - Fax:
Practice Address - Street 1:350 TERRACINA BLVD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4850
Practice Address - Country:US
Practice Address - Phone:909-335-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16615363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP93958Medicare UPIN