Basic Information
Provider Information | |||||||||
NPI: | 1972693661 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PIANKA | ||||||||
FirstName: | CARLA | ||||||||
MiddleName: | A. | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15000 MIDLANTIC DR | ||||||||
Address2: | SUITE 102 | ||||||||
City: | MT. LAUREL | ||||||||
State: | NJ | ||||||||
PostalCode: | 08054 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8562555479 | ||||||||
FaxNumber: | 8563938372 | ||||||||
Practice Location | |||||||||
Address1: | 15000 MIDLANTIC DR | ||||||||
Address2: | SUITE 102 | ||||||||
City: | MT. LAUREL | ||||||||
State: | NJ | ||||||||
PostalCode: | 08054 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8562555479 | ||||||||
FaxNumber: | 8563938372 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/13/2006 | ||||||||
LastUpdateDate: | 03/03/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | MP00018 | NJ | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 25MP00001800 | NJ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.