Provider Demographics
NPI:1558967711
Name:DECTER, LARA BROOKE (PA)
Entity Type:Individual
Prefix:MRS
First Name:LARA
Middle Name:BROOKE
Last Name:DECTER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 E 8TH ST APT 26M
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-6522
Mailing Address - Country:US
Mailing Address - Phone:516-668-7950
Mailing Address - Fax:
Practice Address - Street 1:21 W 19TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10011-4208
Practice Address - Country:US
Practice Address - Phone:516-668-7950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-11
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024816363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty