Healthcare Provider Details

I. General information

NPI: 1164798310
Provider Name (Legal Business Name): LUIS ROSENDO LARA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2012
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 UNIVERSITY DR
HERSHEY PA
17033-2360
US

IV. Provider business mailing address

409 S 2ND ST SUITE 2F
HARRISBURG PA
17104-1612
US

V. Phone/Fax

Practice location:
  • Phone: 717-531-6597
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN555329
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN555329
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: