Provider Demographics
NPI:1801052030
Name:BOONE, CARLY JAY (PA-C)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:JAY
Last Name:BOONE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 N IH 35 E STE 100
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-5267
Mailing Address - Country:US
Mailing Address - Phone:469-800-9500
Mailing Address - Fax:469-800-9540
Practice Address - Street 1:2460 N IH 35 E STE 100
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-5267
Practice Address - Country:US
Practice Address - Phone:469-800-9500
Practice Address - Fax:469-800-9540
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05842363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA05842OtherPHYSCICIAN ASSISTANT LICENSE
TX1082631OtherCERTIFIED PAC