Provider Demographics
NPI:1518303189
Name:ROUTZAHN, CARLY E (PA-C)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:E
Last Name:ROUTZAHN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:E
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3480 WOLVERINE DR STE F
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-4965
Mailing Address - Country:US
Mailing Address - Phone:970-399-5617
Mailing Address - Fax:
Practice Address - Street 1:3480 WOLVERINE DR STE F
Practice Address - Street 2:
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-4965
Practice Address - Country:US
Practice Address - Phone:970-399-5617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-22
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006662363A00000X
COPA.0005999363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP35450047Medicare PIN