Provider Demographics
NPI:1043645690
Name:SMITH, CARLY NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:NICOLE
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5435 FELTL RD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-7983
Mailing Address - Country:US
Mailing Address - Phone:952-835-9880
Mailing Address - Fax:
Practice Address - Street 1:5435 FELTL RD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-7983
Practice Address - Country:US
Practice Address - Phone:952-835-9880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-13
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004730363AM0700X
MN11656363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical