Provider Demographics
NPI:1821317249
Name:BIBART, CARLA DIANE (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:DIANE
Last Name:BIBART
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:22301 FOSTER WINTER DRIVE
Practice Address - Street 2:FLOOR 1
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3713
Practice Address - Country:US
Practice Address - Phone:248-849-3321
Practice Address - Fax:248-849-8448
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005302363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant