Healthcare Provider Details

I. General information

NPI: 1245944198
Provider Name (Legal Business Name): ERIC LARA FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2023
Last Update Date: 12/12/2023
Certification Date: 12/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9445 CALUMET AVE
MUNSTER IN
46321-2811
US

IV. Provider business mailing address

8558 BROADWAY
MERRILLVILLE IN
46410-7032
US

V. Phone/Fax

Practice location:
  • Phone: 219-836-2055
  • Fax: 219-836-0355
Mailing address:
  • Phone: 219-739-2070
  • Fax: 219-703-6854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF0220799
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71014733A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: