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General NPI Number Information
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NPI Number | 1851198303
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Entity Type | Individual
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Provider Name | JASMINE ELISABEL LARA
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Gender |
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Dates
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Enumeration Date | 03/03/2025
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Last Update Date | 03/03/2025
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Provider Practice Location Address
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Address Line | PSC 447 BX 2 FPO-AP
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City | AYASE
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State | KANAGAWA
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Zip | 96306
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Country | JP
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Telephone | 515-943-2978
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Fax |
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Provider Business Mailing Address
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Address Line | 125 WADE STEPHENSON RD
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City | HOLLY SPRINGS
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State | NC
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Zip | 27540-8099
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Country | US
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Telephone | 515-943-2978
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 14192610-1206
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License Number State | UT
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