Healthcare Provider Details

I. General information

NPI: 1194299594
Provider Name (Legal Business Name): BRIAN N LARA APRN-CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2019
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3485 NORTHRISE DR STE 1
LAS CRUCES NM
88011-6839
US

IV. Provider business mailing address

4072 DEMOS AVE
LAS CRUCES NM
88011-4209
US

V. Phone/Fax

Practice location:
  • Phone: 575-382-2161
  • Fax:
Mailing address:
  • Phone: 575-644-9139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number55015
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: