Provider Demographics
NPI:1316240575
Name:CARLY, JAMES E (PA-C)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:E
Last Name:CARLY
Suffix:
Gender:M
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 1:258 S 810 E
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:UT
Mailing Address - Zip Code:84653-4001
Mailing Address - Country:US
Mailing Address - Phone:801-471-3405
Mailing Address - Fax:
Practice Address - Street 1:280 W RIVERPARK DR STE 120
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-229-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-09
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5354572-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU000072942Medicare PIN