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General NPI Number Information
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NPI Number | 1346741501
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Entity Type | Organization
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Legal Business Name | CORAESTHETICS PLLC
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Dates
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Enumeration Date | 02/23/2018
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Last Update Date | 07/09/2018
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Provider Practice Location Address
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Address Line | 2008 E LAGUNA DR
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City | TEMPE
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State | AZ
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Zip | 85282
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Country | US
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Telephone | 480-307-3497
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Fax |
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Provider Business Mailing Address
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Address Line | 2008 E LAGUNA DR
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City | TEMPE
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State | AZ
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Zip | 85282-5915
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MEMBER MANAGER
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Name | JAMIE JENNETTE CORACIDES
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Credential | PA-C
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Telephone | 480-307-3497
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 4462
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License Number State | AZ
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