Provider Demographics
NPI:1386639441
Name:GWARDSCHALADSE, CARLO IVAN (PA)
Entity Type:Individual
Prefix:
First Name:CARLO
Middle Name:IVAN
Last Name:GWARDSCHALADSE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:95 GRASSLANDS RD
Mailing Address - Street 2:MUNGER PAVILION
Mailing Address - City:VALHALLA
Mailing Address - State:NY
Mailing Address - Zip Code:10595-1652
Mailing Address - Country:US
Mailing Address - Phone:914-493-7621
Mailing Address - Fax:914-594-4359
Practice Address - Street 1:19 BRADHURST AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532-2139
Practice Address - Country:US
Practice Address - Phone:914-345-0162
Practice Address - Fax:914-347-4401
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005375363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ22687Medicare UPIN
NY5581L94181Medicare PIN