Healthcare Provider Details

I. General information

NPI: 1245269463
Provider Name (Legal Business Name): ELIDA LIZETH LARA P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 LINCOLN AVE
HAVERHILL MA
01830-6700
US

IV. Provider business mailing address

1 EDWARD ST
CANTON MA
02021-2303
US

V. Phone/Fax

Practice location:
  • Phone: 978-374-2000
  • Fax:
Mailing address:
  • Phone: 781-828-3533
  • Fax: 781-828-2471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number1942
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: