Provider Demographics
NPI:1831277177
Name:KYRIAKATOS, LISA S (PA-C)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:S
Last Name:KYRIAKATOS
Suffix:
Gender:F
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 1:2200 ARCH ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-1330
Mailing Address - Country:US
Mailing Address - Phone:215-561-3363
Mailing Address - Fax:215-561-4129
Practice Address - Street 1:2200 ARCH ST
Practice Address - Street 2:SUITE 102
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-1330
Practice Address - Country:US
Practice Address - Phone:215-561-3363
Practice Address - Fax:215-561-4129
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052810363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA11929JH4Medicare UPIN