Provider Demographics
NPI:1578107660
Name:LASTRA, MEREDITH MARIE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:MEREDITH
Middle Name:MARIE
Last Name:LASTRA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1528 ROCK SPRING RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FOREST HILL
Mailing Address - State:MD
Mailing Address - Zip Code:21050-2861
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2315 BEL AIR RD STE C1
Practice Address - Street 2:
Practice Address - City:FALLSTON
Practice Address - State:MD
Practice Address - Zip Code:21047-2741
Practice Address - Country:US
Practice Address - Phone:443-966-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-31
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024361363A00000X
MDC08380363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant