Provider Demographics
NPI:1497458632
Name:NGUYEN, LARA (PNP)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:MATTIE
Other - Last Name:CHURCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1001 LITTLE OAK WAY
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-5517
Mailing Address - Country:US
Mailing Address - Phone:512-255-8868
Mailing Address - Fax:
Practice Address - Street 1:1001 LITTLE OAK WAY
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-5517
Practice Address - Country:US
Practice Address - Phone:404-786-8424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1032061363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics