Provider Demographics
NPI:1013942762
Name:LARACH, MARY WALKER (ANP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:WALKER
Last Name:LARACH
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-4522
Mailing Address - Country:US
Mailing Address - Phone:336-621-2500
Mailing Address - Fax:336-621-4516
Practice Address - Street 1:2500 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-4522
Practice Address - Country:US
Practice Address - Phone:336-621-2500
Practice Address - Fax:336-621-4516
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC005000027363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7003698Medicaid
Q42516Medicare UPIN
NC7003698Medicaid