Provider Demographics
NPI:1982930459
Name:MYERS, LARA TRAVIS (ACNP, MSN)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:TRAVIS
Last Name:MYERS
Suffix:
Gender:F
Credentials:ACNP, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2280 IVY RD STE 1303
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-4977
Practice Address - Country:US
Practice Address - Phone:434-243-5432
Practice Address - Fax:434-244-4454
Is Sole Proprietor?:No
Enumeration Date:2009-10-19
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024168523207XX0801X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1982930459Medicaid
VA1982930459Medicaid