Provider Demographics
NPI:1477093714
Name:FUKASAWA-LARA, JENNIFER KAORI (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KAORI
Last Name:FUKASAWA-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 1:38905 VISTA DR
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-2156
Mailing Address - Country:US
Mailing Address - Phone:310-408-9476
Mailing Address - Fax:
Practice Address - Street 1:600 N HIGHLAND SPRINGS AVE
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-3046
Practice Address - Country:US
Practice Address - Phone:951-845-1121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-06
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA54259363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant