Provider Demographics
NPI:1306857511
Name:CONAWAY, CAROLYN M (PAC)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:M
Last Name:CONAWAY
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:M
Other - Last Name:BEHM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1051 W US ROUTE 6
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-3349
Mailing Address - Country:US
Mailing Address - Phone:815-942-4875
Mailing Address - Fax:815-942-5046
Practice Address - Street 1:1051 W US ROUTE 6
Practice Address - Street 2:SUITE 100
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-3349
Practice Address - Country:US
Practice Address - Phone:815-942-4875
Practice Address - Fax:815-942-5046
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04919363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085003271OtherIL STATE LICENSE
IL085003271OtherIL PA LICENSE
TXPA04919OtherSTATE LICENSE
TXPA04919OtherSTATE LICENSE
ILP00704592Medicare PIN
IL085003271OtherIL STATE LICENSE
IL208887001Medicare PIN
IL208592Medicare PIN
IL085003271OtherIL PA LICENSE
IL370830012Medicare PIN