Provider Demographics
NPI:1114780491
Name:KOENIG, CARLY ROSE (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ROSE
Last Name:KOENIG
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 1:5 SHERRILL ST
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-1113
Mailing Address - Country:US
Mailing Address - Phone:815-520-2152
Mailing Address - Fax:
Practice Address - Street 1:106 STRANGE RD
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-2540
Practice Address - Country:US
Practice Address - Phone:601-910-3004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-31
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00771363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant