Provider Demographics
NPI:1891074886
Name:LARA, KRISTI MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KRISTI
Middle Name:MARIE
Last Name:LARA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4140 W 190TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5513
Mailing Address - Country:US
Mailing Address - Phone:310-423-8530
Mailing Address - Fax:310-423-4759
Practice Address - Street 1:127 S SAN VICENTE BLVD STE 7TH
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-3311
Practice Address - Country:US
Practice Address - Phone:310-423-8530
Practice Address - Fax:310-423-4759
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2025-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21736363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18762OtherGROUP MEDI-CAL
CAGR0100430OtherGROUP MEDI-CAL
CA1902846306OtherGROUP NPI