Provider Demographics
NPI:1952162539
Name:IWASKIW, LARYSA A (PA-C)
Entity type:Individual
Prefix:
First Name:LARYSA
Middle Name:A
Last Name:IWASKIW
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 1:225 BALDWIN AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3109
Mailing Address - Country:US
Mailing Address - Phone:704-376-1605
Mailing Address - Fax:704-335-8448
Practice Address - Street 1:110 LAKE CONCORD RD NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2918
Practice Address - Country:US
Practice Address - Phone:704-792-2672
Practice Address - Fax:704-792-2674
Is Sole Proprietor?:No
Enumeration Date:2024-01-19
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-14814363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1952162539Medicaid