Provider Demographics
NPI:1578509881
Name:SOLAK, CAROLYN KAY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:KAY
Last Name:SOLAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:CAROLYN
Other - Middle Name:KAY
Other - Last Name:NEDDERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 945395
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30394-5395
Mailing Address - Country:US
Mailing Address - Phone:888-820-9533
Mailing Address - Fax:919-739-8218
Practice Address - Street 1:110 CAPCOM AVE STE 200
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6531
Practice Address - Country:US
Practice Address - Phone:919-229-4046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07295363A00000X
CT001711363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q61156Medicare UPIN
CT970002040Medicare ID - Type Unspecified
Q61156Medicare UPIN
CT970002040Medicare ID - Type Unspecified