Provider Demographics
NPI:1134999519
Name:EWANKO, LORA
Entity type:Individual
Prefix:MRS
First Name:LORA
Middle Name:
Last Name:EWANKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LORA
Other - Middle Name:
Other - Last Name:CHASTAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 N BEELINE HWY
Mailing Address - Street 2:
Mailing Address - City:PAYSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85541-4305
Mailing Address - Country:US
Mailing Address - Phone:928-472-2826
Mailing Address - Fax:928-472-2815
Practice Address - Street 1:300 N BEELINE HWY
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:AZ
Practice Address - Zip Code:85541-4305
Practice Address - Country:US
Practice Address - Phone:928-472-2826
Practice Address - Fax:928-472-2815
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician