Provider Demographics
NPI:1740364124
Name:DAVIS, LARA M (PA)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:M
Other - Last Name:GALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3452 GENESYS PKWY
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48439-7334
Mailing Address - Country:US
Mailing Address - Phone:810-606-7550
Mailing Address - Fax:
Practice Address - Street 1:3452 GENESYS PKWY
Practice Address - Street 2:
Practice Address - City:GRAND BLANC
Practice Address - State:MI
Practice Address - Zip Code:48439-7334
Practice Address - Country:US
Practice Address - Phone:810-606-7550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005217363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP74009Medicare UPIN
ILK37753Medicare PIN