Provider Demographics
NPI:1821709833
Name:KOLTA, DEMIANA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:DEMIANA
Middle Name:MARIE
Last Name:KOLTA
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 1:14445 W MCDOWELL RD STE A104
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-2518
Mailing Address - Country:US
Mailing Address - Phone:480-561-5000
Mailing Address - Fax:480-984-4066
Practice Address - Street 1:14445 W MCDOWELL RD STE A104
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2518
Practice Address - Country:US
Practice Address - Phone:480-561-5000
Practice Address - Fax:480-984-4066
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9992363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant