Provider Demographics
NPI:1114624996
Name:BYAS, LATORIA KIESTA
Entity Type:Individual
Prefix:
First Name:LATORIA
Middle Name:KIESTA
Last Name:BYAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 JONESTOWN ROAD SPC #74
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109
Mailing Address - Country:US
Mailing Address - Phone:717-635-8238
Mailing Address - Fax:
Practice Address - Street 1:4600 JONESTOWN ROAD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109
Practice Address - Country:US
Practice Address - Phone:717-635-8238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier