Provider Demographics
NPI:1891207775
Name:STILLMAN, CARLY ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:ANN
Last Name:STILLMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 JB CT
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD SPGS
Mailing Address - State:CO
Mailing Address - Zip Code:81601-8733
Mailing Address - Country:US
Mailing Address - Phone:970-379-1775
Mailing Address - Fax:
Practice Address - Street 1:350 MARKET ST UNIT 316
Practice Address - Street 2:
Practice Address - City:BASALT
Practice Address - State:CO
Practice Address - Zip Code:81621-7405
Practice Address - Country:US
Practice Address - Phone:970-927-1141
Practice Address - Fax:970-422-7123
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPENDING363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant