Provider Demographics
NPI:1184715260
Name:NEVULIS, CAROL (PAC)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:NEVULIS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:
Other - Last Name:JUBIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:2233 STATE ROUTE 86
Mailing Address - Street 2:
Mailing Address - City:SARANAC LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12983-5644
Mailing Address - Country:US
Mailing Address - Phone:518-891-4141
Mailing Address - Fax:
Practice Address - Street 1:2233 STATE ROUTE 86
Practice Address - Street 2:
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-5644
Practice Address - Country:US
Practice Address - Phone:518-891-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA001333L363AS0400X
NY002877363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAS34526Medicare UPIN
PAS34526Medicare UPIN