MEDICARE: CORAESTHETICS PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	4462	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4462	OTHER	AZ	PHYSICIAN ASSISTANT LICENCE

General Provider Information

NPI Number	:	1346741501
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CORAESTHETICS PLLC

Provider Business Mailing Address
First Line	:	2008 E LAGUNA DR
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85282-5915
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2008 E LAGUNA DR
Second Line	:
City	:	TEMPE
State	:	AZ
Zip	:	85282
Country	:	US
Telephone Number	:	480-307-3497
Fax Number	:

Authorized Official
Title or Position	:	MEMBER MANAGER
Name	:	JAMIE JENNETTE CORACIDES
Credential	:	PA-C
Telephone Number	:	480-307-3497

Provider Enumeration Date	:	02/23/2018
Last Update Date	:	07/09/2018

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