Basic Information
| Provider Information | |||||||||
| NPI: | 1154315430 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HALE | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 N L ROGERS WELLS BLVD | ||||||||
| Address2: | |||||||||
| City: | GLASGOW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421411300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706595885 | ||||||||
| FaxNumber: | 2706595852 | ||||||||
| Practice Location | |||||||||
| Address1: | 310 N L ROGERS WELLS BLVD | ||||||||
| Address2: | |||||||||
| City: | GLASGOW | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421411300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2706595885 | ||||||||
| FaxNumber: | 2706595852 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2005 | ||||||||
| LastUpdateDate: | 10/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA325 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 9500246500 | 05 | KY | MEDICAID |