Healthcare Provider Details

I. General information

NPI: 1174188668
Provider Name (Legal Business Name): CARLY ZOE SWETT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2019
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 TEBEAU ST
WAYCROSS GA
31501-6357
US

IV. Provider business mailing address

2227 GALLOWAY AVE
BISHOP CA
93514-2017
US

V. Phone/Fax

Practice location:
  • Phone: 760-937-1852
  • Fax:
Mailing address:
  • Phone: 760-937-1852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9986
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: