Provider Demographics
NPI:1265839708
Name:BALAYAN, KONSTANTIN W (PA-C)
Entity Type:Individual
Prefix:
First Name:KONSTANTIN
Middle Name:W
Last Name:BALAYAN
Suffix:
Gender:M
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 1:6426 COLDWATER CANYON AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-1113
Mailing Address - Country:US
Mailing Address - Phone:818-927-4112
Mailing Address - Fax:818-308-6351
Practice Address - Street 1:6426 COLDWATER CANYON AVE
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91606-1113
Practice Address - Country:US
Practice Address - Phone:818-927-4112
Practice Address - Fax:818-308-6351
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA52133363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant