Provider Demographics
NPI:1053292912
Name:LARA, ANGEL L
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:L
Last Name:LARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8802 POE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-1922
Mailing Address - Country:US
Mailing Address - Phone:305-967-3508
Mailing Address - Fax:
Practice Address - Street 1:8802 POE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33615-1922
Practice Address - Country:US
Practice Address - Phone:305-967-3508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-09
Last Update Date:2025-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL28508225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant