Provider Demographics
NPI:1114228517
Name:CHONG, CARLA (PA)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:CHONG
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:
Other - Last Name:CORDOVA-EDUAVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5310 KIETZKE LN STE 104
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-2043
Mailing Address - Country:US
Mailing Address - Phone:775-348-8800
Mailing Address - Fax:833-687-1419
Practice Address - Street 1:9480 DOUBLE DIAMOND PKWY STE 200
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-5842
Practice Address - Country:US
Practice Address - Phone:775-348-8800
Practice Address - Fax:833-687-1419
Is Sole Proprietor?:No
Enumeration Date:2010-11-16
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1241363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1114228517Medicaid
NV1114228517Medicaid
NVPA1241OtherNV PHYSICIAN ASSISTANT LICENSE #