Provider Demographics
NPI:1730176140
Name:POWERS, LARA M (MD)
Entity type:Individual
Prefix:DR
First Name:LARA
Middle Name:M
Last Name:POWERS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:MARIE
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1409 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-3918
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:1409 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-3918
Practice Address - Country:US
Practice Address - Phone:715-732-0832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45322020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34346300Medicaid
P00104680OtherRR MEDICARE
H33279Medicare UPIN
P00104680OtherRR MEDICARE
WI34346300Medicaid