Provider Demographics
NPI:1174188668
Name:SWETT, CARLY ZOE (PA-C)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:ZOE
Last Name:SWETT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2227 GALLOWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BISHOP
Mailing Address - State:CA
Mailing Address - Zip Code:93514-2017
Mailing Address - Country:US
Mailing Address - Phone:760-937-1852
Mailing Address - Fax:
Practice Address - Street 1:1900 TEBEAU ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-6357
Practice Address - Country:US
Practice Address - Phone:760-937-1852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-09
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA9986363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program