Provider Demographics
NPI:1629564729
Name:KRISAVAGE, CARLY (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:KRISAVAGE
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:
Other - Last Name:KRISAVAGE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:11 STONEFIELD DR
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:CT
Mailing Address - Zip Code:06712-1744
Mailing Address - Country:US
Mailing Address - Phone:203-592-4376
Mailing Address - Fax:
Practice Address - Street 1:161 BOSTON AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-1662
Practice Address - Country:US
Practice Address - Phone:203-333-4400
Practice Address - Fax:203-334-0729
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4141363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant