Provider Demographics
NPI:1679758700
Name:MAUCH, CARLY (PA-C)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:MAUCH
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 1:2423 NW TROOST ST
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-1706
Mailing Address - Country:US
Mailing Address - Phone:541-677-3400
Mailing Address - Fax:541-677-3405
Practice Address - Street 1:1813 W HARVARD AVE
Practice Address - Street 2:SUITE #310
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2752
Practice Address - Country:US
Practice Address - Phone:541-672-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORPA01409363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR144364OtherPTAN