Provider Demographics
NPI:1750149803
Name:LARA MEDRANO, NICOLAS MATIAS
Entity type:Individual
Prefix:
First Name:NICOLAS
Middle Name:MATIAS
Last Name:LARA MEDRANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10308 COLESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-1941
Mailing Address - Country:US
Mailing Address - Phone:301-605-3026
Mailing Address - Fax:
Practice Address - Street 1:6410 ROCKLEDGE DR STE 600
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-1844
Practice Address - Country:US
Practice Address - Phone:240-833-7354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program