Provider Demographics
NPI:1518109040
Name:PIERCE, LARA MARINA (MD)
Entity Type:Individual
Prefix:MRS
First Name:LARA
Middle Name:MARINA
Last Name:PIERCE
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 1:215 CHISHOLM TRAIL DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TX-TEXAS
Mailing Address - Zip Code:76458
Mailing Address - Country:UM
Mailing Address - Phone:940-567-5528
Mailing Address - Fax:
Practice Address - Street 1:215 CHISHOLM TRL
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TX
Practice Address - Zip Code:76458-1403
Practice Address - Country:US
Practice Address - Phone:940-567-5528
Practice Address - Fax:940-567-6325
Is Sole Proprietor?:No
Enumeration Date:2009-03-30
Last Update Date:2015-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP4368207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXP4368OtherSTATE LICENSE