Provider Demographics
NPI:1487046397
Name:TREVINO, LARA (NP)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:TREVINO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 W BURNSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-4015
Mailing Address - Country:US
Mailing Address - Phone:718-716-4400
Mailing Address - Fax:
Practice Address - Street 1:304 W 88TH ST
Practice Address - Street 2:3D
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-2227
Practice Address - Country:US
Practice Address - Phone:214-864-4882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-02
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY691374-1163W00000X
NYF307592-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse