Provider Demographics
NPI:1154315430
Name:HALE, CARLA JO (PAC)
Entity Type:Individual
Prefix:MRS
First Name:CARLA
Middle Name:JO
Last Name:HALE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:310 N L ROGERS WELLS BLVD
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-1300
Mailing Address - Country:US
Mailing Address - Phone:270-659-5885
Mailing Address - Fax:270-659-5852
Practice Address - Street 1:310 N L ROGERS WELLS BLVD
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-1300
Practice Address - Country:US
Practice Address - Phone:270-659-5885
Practice Address - Fax:270-659-5852
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA325363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY9500246500Medicaid
KY9500246500Medicaid
P26716Medicare UPIN