Provider Demographics
NPI:1942500541
Name:CONLEY, CARRIE LYNN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:CARRIE
Middle Name:LYNN
Last Name:CONLEY
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 1:1919 LATHROP ST
Mailing Address - Street 2:STE 106
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701
Mailing Address - Country:US
Mailing Address - Phone:907-455-7123
Mailing Address - Fax:907-455-7125
Practice Address - Street 1:1919 LATHROP ST
Practice Address - Street 2:STE 106
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701
Practice Address - Country:US
Practice Address - Phone:907-455-7123
Practice Address - Fax:907-455-7125
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-28
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60188305363AM0700X
AKPADA996363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1597181Medicaid
AK1597181Medicaid