Provider Demographics
NPI:1164705430
Name:REISING, CARLY KATHLEEN (PA)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:KATHLEEN
Last Name:REISING
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:
Other - Last Name:GIETLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:7500 CHALLIS RD FL 1
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-9416
Practice Address - Country:US
Practice Address - Phone:810-263-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004054363A00000X
MI5601007564363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1164705430Medicaid
MI1164705430Medicaid