Provider Demographics
NPI:1164422366
Name:VAVALA, CARLA A (PA)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:A
Last Name:VAVALA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2004
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-4504
Mailing Address - Country:US
Mailing Address - Phone:315-362-5285
Mailing Address - Fax:315-445-2936
Practice Address - Street 1:736 IRVING AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1687
Practice Address - Country:US
Practice Address - Phone:315-470-7551
Practice Address - Fax:315-470-2719
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2008-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010379363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00325843Medicare PIN
Q40761Medicare UPIN