Provider Demographics
NPI:1811274616
Name:MCNUTT, CARLY J (PA-C)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:J
Last Name:MCNUTT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:
Other - Last Name:RADCLIFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2580 HAYMAKER RD STE 304
Mailing Address - Street 2:
Mailing Address - City:MONROEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15146-3500
Mailing Address - Country:US
Mailing Address - Phone:412-858-3070
Mailing Address - Fax:412-858-3076
Practice Address - Street 1:2580 HAYMAKER RD STE 304
Practice Address - Street 2:
Practice Address - City:MONROEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15146-3500
Practice Address - Country:US
Practice Address - Phone:412-858-3070
Practice Address - Fax:412-858-3076
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA055049363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
13576963OtherCAQH
PA103195249Medicaid