Basic Information
| Provider Information | |||||||||
| NPI: | 1083621254 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NAKAO | ||||||||
| FirstName: | LARA | ||||||||
| MiddleName: | JOY | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1308 DEKALB ST | ||||||||
| Address2: | |||||||||
| City: | NORRISTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194013404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102798686 | ||||||||
| FaxNumber: | 6102791588 | ||||||||
| Practice Location | |||||||||
| Address1: | 1308 DEKALB ST | ||||||||
| Address2: | |||||||||
| City: | NORRISTOWN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 194013404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6102798686 | ||||||||
| FaxNumber: | 6102791588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 05/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110004556 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | MA051881 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 50051163 | 01 | PA | BLUE CROSS | OTHER |