Provider Demographics
NPI:1801229356
Name:CONOVALOFF, LARA (PA-C)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:CONOVALOFF
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 1:6430 SELMA AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90028-7311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6430 SELMA AVE
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90028-7311
Practice Address - Country:US
Practice Address - Phone:323-848-4522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23167363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical