Provider Demographics
NPI:1295389849
Name:HADDOCK, CARLY ELIZABETH (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ELIZABETH
Last Name:HADDOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:ELIZABETH
Other - Last Name:MISCHELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:701 OSTRUM ST STE 201
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN HILL
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1152
Mailing Address - Country:US
Mailing Address - Phone:484-526-6545
Mailing Address - Fax:484-526-6546
Practice Address - Street 1:701 OSTRUM ST STE 201
Practice Address - Street 2:
Practice Address - City:FOUNTAIN HILL
Practice Address - State:PA
Practice Address - Zip Code:18015-1152
Practice Address - Country:US
Practice Address - Phone:484-526-6545
Practice Address - Fax:484-526-6546
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-006780207Q00000X
PAMA062781363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine