Provider Demographics
NPI:1013290410
Name:WAGNER VON HOFF, CAROLYN RENEE (PAC)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:RENEE
Last Name:WAGNER VON HOFF
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:DECARLI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:18444 N 25TH AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1266
Mailing Address - Country:US
Mailing Address - Phone:866-974-2673
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:3591 S MERCY RD STE 204
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-2240
Practice Address - Country:US
Practice Address - Phone:866-974-2673
Practice Address - Fax:866-939-2673
Is Sole Proprietor?:No
Enumeration Date:2011-09-21
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4954363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ4954OtherARIZONA BOARD OF PHYSICIAN ASSISTANTS