Provider Demographics
NPI:1558123943
Name:DE VARGAS, LARA (PTA)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:DE VARGAS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1778 W 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:APACHE JUNCTION
Mailing Address - State:AZ
Mailing Address - Zip Code:85120-6930
Mailing Address - Country:US
Mailing Address - Phone:714-402-4136
Mailing Address - Fax:
Practice Address - Street 1:4210 E BASELINE RD STE 106
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4418
Practice Address - Country:US
Practice Address - Phone:480-503-2373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ014433225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant