Provider Demographics
NPI:1215309695
Name:BLACK, CARLA LOUISE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:LOUISE
Last Name:BLACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:CARLA
Other - Middle Name:LOUISE
Other - Last Name:LONGANECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 110429
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80042-0429
Mailing Address - Country:US
Mailing Address - Phone:303-493-7000
Mailing Address - Fax:
Practice Address - Street 1:12605 E 16TH AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045-2545
Practice Address - Country:US
Practice Address - Phone:720-848-0000
Practice Address - Fax:720-848-4293
Is Sole Proprietor?:No
Enumeration Date:2015-10-26
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004432363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant