Provider Demographics
NPI:1427573039
Name:ROME, CARLY JILL (PA)
Entity Type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:JILL
Last Name:ROME
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:JILL
Other - Last Name:LEVANTHAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:555 W 23RD ST APT S12F
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10011-1027
Mailing Address - Country:US
Mailing Address - Phone:203-980-5958
Mailing Address - Fax:
Practice Address - Street 1:5 COLUMBUS CIRCLE
Practice Address - Street 2:8TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1412
Practice Address - Country:US
Practice Address - Phone:212-590-5580
Practice Address - Fax:212-590-5581
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-04
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY021097OtherLICENSE