Provider Demographics
NPI:1992030316
Name:WALLIS, CARLY M (MS, RPA-C)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:M
Last Name:WALLIS
Suffix:
Gender:F
Credentials:MS, RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:ZANESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43701-2820
Mailing Address - Country:US
Mailing Address - Phone:740-454-7546
Mailing Address - Fax:
Practice Address - Street 1:817 FOREST AVE
Practice Address - Street 2:
Practice Address - City:ZANESVILLE
Practice Address - State:OH
Practice Address - Zip Code:43701-2820
Practice Address - Country:US
Practice Address - Phone:740-454-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-04
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50005259RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant