Provider Demographics
NPI:1376512319
Name:KONEY-LARYEA, CANDACE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
Last Name:KONEY-LARYEA
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 1:5424 GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652
Mailing Address - Country:US
Mailing Address - Phone:727-845-1736
Mailing Address - Fax:727-849-0759
Practice Address - Street 1:14000 FIVAY RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667
Practice Address - Country:US
Practice Address - Phone:727-861-5155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2016-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90158207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL271759000Medicaid
FL43004ZMedicare ID - Type Unspecified
I05177Medicare UPIN