Provider Demographics
NPI:1629627401
Name:REIGART, CARLY JO (PA)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:JO
Last Name:REIGART
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:JO
Other - Last Name:BOLTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:601 MEMORY LN
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17402-2231
Mailing Address - Country:US
Mailing Address - Phone:717-851-6110
Mailing Address - Fax:717-741-1076
Practice Address - Street 1:300 PINE GROVE CMNS
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17403-5176
Practice Address - Country:US
Practice Address - Phone:717-851-6110
Practice Address - Fax:717-741-1076
Is Sole Proprietor?:No
Enumeration Date:2019-09-05
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060736363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty