Provider Demographics
NPI:1023240462
Name:OVERLAND, CARLY R (PA-C)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:R
Last Name:OVERLAND
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:R
Other - Last Name:SODA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5 MARKET PL
Mailing Address - Street 2:SUITE 50
Mailing Address - City:NEW HOPE
Mailing Address - State:PA
Mailing Address - Zip Code:18938-1059
Mailing Address - Country:US
Mailing Address - Phone:215-862-6000
Mailing Address - Fax:215-862-4567
Practice Address - Street 1:670 LAWN AVE STE A
Practice Address - Street 2:
Practice Address - City:SELLERSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18960-1571
Practice Address - Country:US
Practice Address - Phone:215-257-0196
Practice Address - Fax:215-257-1211
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-19
Last Update Date:2019-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054133363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA164929V4CMedicare PIN
PA164929V4BMedicare PIN