Provider Demographics
NPI:1417368838
Name:CARLISLE, GARY
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:CARLISLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 E 58TH ST
Mailing Address - Street 2:25TH FL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10155-0002
Mailing Address - Country:US
Mailing Address - Phone:212-223-2920
Mailing Address - Fax:212-223-2390
Practice Address - Street 1:150 E 58TH ST
Practice Address - Street 2:25TH FL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10155-0002
Practice Address - Country:US
Practice Address - Phone:212-223-2920
Practice Address - Fax:212-223-2390
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF401463-1363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health