Provider Demographics
NPI:1891840609
Name:MOODIE, CARLA C (PA C)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:C
Last Name:MOODIE
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 1:737 MAIN ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:LUMBERTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08048-3089
Mailing Address - Country:US
Mailing Address - Phone:609-267-9400
Mailing Address - Fax:
Practice Address - Street 1:737 MAIN ST
Practice Address - Street 2:SUITE 6
Practice Address - City:LUMBERTON
Practice Address - State:NJ
Practice Address - Zip Code:08048-3089
Practice Address - Country:US
Practice Address - Phone:609-267-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00173900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant