Basic Information
| Provider Information | |||||||||
| NPI: | 1205283561 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | CARLY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1150 S COLONY WAY STE 3 | ||||||||
| Address2: | |||||||||
| City: | PALMER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996456972 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 17025 SNOWMOBILE LN | ||||||||
| Address2: | |||||||||
| City: | EAGLE RIVER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995777044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9076949553 | ||||||||
| FaxNumber: | 9076949585 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2016 | ||||||||
| LastUpdateDate: | 09/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 126320 | AK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1679133 | 05 | AK | MEDICAID |