Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2084N0402X | Child Neurologist | 25MA05442600 | NJ |
NPI | 1144249137 |
---|---|
Provider Name | Carlos Lastra |
First Address | New Brunswick, NJ 08901-1766 |
Second Address | New Brunswick, NJ 08901-1766 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7295804 | (05) | NJ |
F92326 | (02) | NJ |