Provider Demographics
NPI:1205087699
Name:ERARD, CARLY MARIE BASIRICO (PA)
Entity type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:MARIE BASIRICO
Last Name:ERARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2295 S VINEYARD AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-7925
Mailing Address - Country:US
Mailing Address - Phone:909-724-3083
Mailing Address - Fax:
Practice Address - Street 1:2295 S VINEYARD AVE
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-7925
Practice Address - Country:US
Practice Address - Phone:909-724-3083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-04
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19878363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant