Provider Demographics
NPI:1447979356
Name:KORYAKOS, LAINA (PA-C)
Entity type:Individual
Prefix:
First Name:LAINA
Middle Name:
Last Name:KORYAKOS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6630 W VIA DONA RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85083-7411
Mailing Address - Country:US
Mailing Address - Phone:602-516-6746
Mailing Address - Fax:
Practice Address - Street 1:16841 N 31ST AVE STE 130
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-3051
Practice Address - Country:US
Practice Address - Phone:602-491-0703
Practice Address - Fax:833-431-2257
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ363AM0700X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical