Provider Demographics
NPI:1508440363
Name:PASTILOCK, CARLY ANN
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ANN
Last Name:PASTILOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 LIBERTY DR
Mailing Address - Street 2:
Mailing Address - City:YARDLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19067-4511
Mailing Address - Country:US
Mailing Address - Phone:267-566-3603
Mailing Address - Fax:
Practice Address - Street 1:2601 HOLME AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-2007
Practice Address - Country:US
Practice Address - Phone:215-335-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP023354363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care