Healthcare Provider Details

I. General information

NPI: 1629627401
Provider Name (Legal Business Name): CARLY JO REIGART PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARLY JO BOLTON PA

II. Dates (important events)

Enumeration Date: 09/05/2019
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MONUMENT RD STE 290
YORK PA
17403-5073
US

IV. Provider business mailing address

601 MEMORY LN
YORK PA
17402-2231
US

V. Phone/Fax

Practice location:
  • Phone: 717-812-4090
  • Fax: 717-812-4092
Mailing address:
  • Phone: 717-851-6110
  • Fax: 717-741-1076

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA060736
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: