Provider Demographics
NPI:1225042443
Name:CARLISLE, SUSAN (RPA-C)
Entity Type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:CARLISLE
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:607-266-9310
Practice Address - Street 1:10 BRENTWOOD DR
Practice Address - Street 2:SUITE B
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1865
Practice Address - Country:US
Practice Address - Phone:607-266-0073
Practice Address - Fax:607-266-9310
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0000081363A00000X
NY005198-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01611072Medicaid
NYS11369Medicare UPIN