Provider Demographics
NPI:1659523561
Name:KOKENOS, LARA BETH (PA)
Entity Type:Individual
Prefix:
First Name:LARA
Middle Name:BETH
Last Name:KOKENOS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 HOPE ST APT 3G
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06906-1330
Mailing Address - Country:US
Mailing Address - Phone:203-257-1829
Mailing Address - Fax:
Practice Address - Street 1:425 POST RD FL 2
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6232
Practice Address - Country:US
Practice Address - Phone:203-254-1576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002163363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT002163OtherPA LICENSE
CTML1861170OtherDEA