Healthcare Provider Details

I. General information

NPI: 1295397222
Provider Name (Legal Business Name): CARLEY BROOKE NEINAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARLEY BROOKE BATES

II. Dates (important events)

Enumeration Date: 06/29/2019
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

273 GRANDVIEW AVE
HONESDALE PA
18431-1163
US

IV. Provider business mailing address

707 E MAIN ST
MIDDLETOWN NY
10940-2650
US

V. Phone/Fax

Practice location:
  • Phone: 570-390-4545
  • Fax: 570-390-4546
Mailing address:
  • Phone: 845-333-7575
  • Fax: 845-333-7139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA061098
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number023873
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: