Provider Demographics
NPI:1831112754
Name:LARA, ROSEMARIE (NP)
Entity Type:Individual
Prefix:
First Name:ROSEMARIE
Middle Name:
Last Name:LARA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11755 PALMS BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-2030
Mailing Address - Country:US
Mailing Address - Phone:310-968-9277
Mailing Address - Fax:
Practice Address - Street 1:300 MEDICAL PLAZA
Practice Address - Street 2:#200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-0001
Practice Address - Country:US
Practice Address - Phone:310-825-5111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN508763363L00000X
CANP13828363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN508763Medicaid
CARN508763Medicaid
CAWNP16180AMedicare PIN