Provider Demographics
NPI:1184057473
Name:LARA, JESSICA LYNN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LYNN
Last Name:LARA
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 1:2861 W 120TH AVE
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80234-2987
Mailing Address - Country:US
Mailing Address - Phone:720-295-1229
Mailing Address - Fax:
Practice Address - Street 1:2861 W 120TH AVE
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80234-2987
Practice Address - Country:US
Practice Address - Phone:720-295-1229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-10
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003739363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant