Provider Demographics
NPI:1609244300
Name:KINDBOM, CARLY ANN (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:CARLY
Middle Name:ANN
Last Name:KINDBOM
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:3400 SPRUCE ST
Mailing Address - Street 2:9 GATES
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4238
Mailing Address - Country:US
Mailing Address - Phone:215-662-7355
Mailing Address - Fax:215-349-8444
Practice Address - Street 1:3400 CIVIC CENTER BLVD.
Practice Address - Street 2:EAST PAVILION, 2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4306
Practice Address - Country:US
Practice Address - Phone:215-615-4949
Practice Address - Fax:215-615-0829
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-11
Last Update Date:2022-12-09
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Provider Licenses
StateLicense IDTaxonomies
PAMA058356363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant