Provider Demographics
NPI:1245896968
Name:JIANG, CAROLYN ALYCE (DO)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ALYCE
Last Name:JIANG
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:ALYCE
Other - Last Name:SONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:4700 LAS VEGAS BLVD N
Mailing Address - Street 2:
Mailing Address - City:NELLIS AFB
Mailing Address - State:NV
Mailing Address - Zip Code:89191-6600
Mailing Address - Country:US
Mailing Address - Phone:702-653-2273
Mailing Address - Fax:
Practice Address - Street 1:4700 LAS VEGAS BLVD N
Practice Address - Street 2:
Practice Address - City:NELLIS AFB
Practice Address - State:NV
Practice Address - Zip Code:89191-6600
Practice Address - Country:US
Practice Address - Phone:702-653-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-17
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102206541207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty