Provider Demographics
NPI:1588840409
Name:HAMMER, CARLY D (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:D
Last Name:HAMMER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:DAWN
Other - Last Name:SCHNEIDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:208-381-6505
Practice Address - Street 1:701 E PARKCENTER BLVD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6528
Practice Address - Country:US
Practice Address - Phone:208-381-6500
Practice Address - Fax:208-381-6505
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2012-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-759363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8081651Medicaid
ID8081651Medicaid