Provider Demographics
NPI:1073846176
Name:CORACIDES, JAMIE JENNETTE (PA)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:JENNETTE
Last Name:CORACIDES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:
Other - Last Name:JENNETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2008 E LAGUNA DR
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-5915
Mailing Address - Country:US
Mailing Address - Phone:480-307-3497
Mailing Address - Fax:
Practice Address - Street 1:13400 E SHEA BLVD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85259-5452
Practice Address - Country:US
Practice Address - Phone:480-301-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-08
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4462363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ459374Medicaid
AZ459374Medicaid