Provider Demographics
NPI:1952330524
Name:GROVATT, CARLA Y (PA-C)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:Y
Last Name:GROVATT
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 1:4 EVES DR STE A100
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3126
Mailing Address - Country:US
Mailing Address - Phone:609-267-9400
Mailing Address - Fax:609-267-9457
Practice Address - Street 1:131 ROUTE 70 W
Practice Address - Street 2:STE 100
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055
Practice Address - Country:US
Practice Address - Phone:609-267-9400
Practice Address - Fax:609-267-9457
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00000700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0342921Medicaid
S48997Medicare UPIN
NJ0342921Medicaid
NJ004796Medicare PIN