Provider Demographics
NPI:1861229791
Name:FON, CAROLYN ROSE (PA)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ROSE
Last Name:FON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:20 MILDRED AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2979
Mailing Address - Country:US
Mailing Address - Phone:914-584-3643
Mailing Address - Fax:607-251-2010
Practice Address - Street 1:3101 SHIPPERS RD STE 203
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-2082
Practice Address - Country:US
Practice Address - Phone:607-786-4822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA065946363A00000X
NY032664363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant