Provider Demographics
NPI:1548522279
Name:PARADIANG, LARA PAGOTAISIDRO (PT)
Entity type:Individual
Prefix:MRS
First Name:LARA
Middle Name:PAGOTAISIDRO
Last Name:PARADIANG
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1026 MCFARLAND ST
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-3443
Mailing Address - Country:US
Mailing Address - Phone:423-473-5611
Mailing Address - Fax:
Practice Address - Street 1:1026 MCFARLAND ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3443
Practice Address - Country:US
Practice Address - Phone:423-473-5611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9344225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist