Provider Demographics
NPI:1427741362
Name:DI CARLO, ASA MARIE ATWATER (PA-C)
Entity type:Individual
Prefix:
First Name:ASA
Middle Name:MARIE ATWATER
Last Name:DI CARLO
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 1:2604 SE 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-1110
Mailing Address - Country:US
Mailing Address - Phone:503-367-6833
Mailing Address - Fax:
Practice Address - Street 1:448 N WERTH BLVD
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-7500
Practice Address - Country:US
Practice Address - Phone:503-554-2516
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-26
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WAPA61525974363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant