Provider Demographics
NPI:1861761975
Name:LARA, ANNA ALLER (PAC)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:ALLER
Last Name:LARA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:A
Other - Last Name:LARA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PAC
Mailing Address - Street 1:1325 N 600 E STE 102
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-6744
Mailing Address - Country:US
Mailing Address - Phone:435-753-9999
Mailing Address - Fax:435-753-2301
Practice Address - Street 1:1325 N 600 E STE 102
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-6744
Practice Address - Country:US
Practice Address - Phone:435-753-9999
Practice Address - Fax:435-753-2301
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8170100-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant