Provider Demographics
NPI:1205283561
Name:THOMAS, CARLY (MPAS, PA-C)
Entity type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:
Last Name:THOMAS
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:694 W DESERT BROOM DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-3844
Mailing Address - Country:US
Mailing Address - Phone:503-621-7381
Mailing Address - Fax:
Practice Address - Street 1:1066 N POWER RD STE 101
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-5709
Practice Address - Country:US
Practice Address - Phone:602-288-6776
Practice Address - Fax:480-776-0025
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-17
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK126320363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1679133Medicaid