Provider Demographics
NPI:1003387572
Name:MCILWAIN, CARISSA SUSAN (PA-C)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:SUSAN
Last Name:MCILWAIN
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 1:19 OLD OAKS RD
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-1024
Mailing Address - Country:US
Mailing Address - Phone:610-564-5739
Mailing Address - Fax:
Practice Address - Street 1:25 BALA AVE STE 205
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-3215
Practice Address - Country:US
Practice Address - Phone:610-667-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA002318207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology