Basic Information
| Provider Information | |||||||||
| NPI: | 1700065612 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CALLAHAN | ||||||||
| FirstName: | LARA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | RDMS, PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10170 SORRENTO VALLEY RD | ||||||||
| Address2: | MAIL DROP SV-5 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921211604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8587845888 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10666 N TORREY PINES RD | ||||||||
| Address2: | |||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920371027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586786886 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2007 | ||||||||
| LastUpdateDate: | 01/14/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 19154 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.