Provider Demographics
NPI:1558918029
Name:PERKINS, LARA (DPT)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:PERKINS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:ANN
Other - Last Name:WYRSTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3240 QUEENSBURY DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7017
Mailing Address - Country:US
Mailing Address - Phone:703-861-1626
Mailing Address - Fax:
Practice Address - Street 1:1015 WEST 47TH STREET
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23529-0001
Practice Address - Country:US
Practice Address - Phone:757-683-4228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAPT011597225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist