Basic Information
| Provider Information | |||||||||
| NPI: | 1164422366 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAVALA | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2004 | ||||||||
| Address2: | |||||||||
| City: | EAST SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130574504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153625285 | ||||||||
| FaxNumber: | 3154452936 | ||||||||
| Practice Location | |||||||||
| Address1: | 736 IRVING AVE | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132101687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154707551 | ||||||||
| FaxNumber: | 3154702719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 11/19/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 010379 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.