Provider Demographics
NPI:1821525270
Name:O'CONNOR, CARLY JENNA (PA)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:JENNA
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2159 BURGENER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-1103
Mailing Address - Country:US
Mailing Address - Phone:408-515-4036
Mailing Address - Fax:
Practice Address - Street 1:9898 GENESEE AVE # AMP410
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1205
Practice Address - Country:US
Practice Address - Phone:858-824-5383
Practice Address - Fax:858-964-3125
Is Sole Proprietor?:No
Enumeration Date:2017-05-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
P31438146L00000X
CA54426363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic