Provider Demographics
NPI:1316417157
Name:BACON, CARLEY JEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLEY
Middle Name:JEAN
Last Name:BACON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CARLEY
Other - Middle Name:JEAN
Other - Last Name:SCHWARTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-1166
Mailing Address - Fax:612-262-9035
Practice Address - Street 1:701 DELLWOOD ST S
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MN
Practice Address - Zip Code:55008-1920
Practice Address - Country:US
Practice Address - Phone:763-689-8700
Practice Address - Fax:763-688-7941
Is Sole Proprietor?:No
Enumeration Date:2018-12-04
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA12540363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical