MEDICARE: ALEXANDRIA J LARA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1184350043
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXANDRIA J LARA

Provider Business Mailing Address
First Line	:	2645 N FARWELL AVE APT 110
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53211-3785
Country	:	US
Telephone Number	:	608-331-0644
Fax Number	:

Provider Business Practice Location Address
First Line	:	1821 N 16TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53205-1626
Country	:	US
Telephone Number	:	414-977-0001
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/25/2022
Last Update Date	:	07/25/2022

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