Healthcare Provider Details

I. General information

NPI: 1003633025
Provider Name (Legal Business Name): CARLY COLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2024
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 CLUB DR
VALLEJO CA
94592-1187
US

IV. Provider business mailing address

900 CAMBRIDGE DR UNIT 55
BENICIA CA
94510-3627
US

V. Phone/Fax

Practice location:
  • Phone: 707-638-5809
  • Fax:
Mailing address:
  • Phone: 562-292-2080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: