Provider Demographics
NPI:1619612520
Name:MAWN, MCKAYLA
Entity Type:Individual
Prefix:
First Name:MCKAYLA
Middle Name:
Last Name:MAWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2128 KATER ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-1215
Mailing Address - Country:US
Mailing Address - Phone:484-844-0970
Mailing Address - Fax:
Practice Address - Street 1:3400 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4238
Practice Address - Country:US
Practice Address - Phone:215-662-3797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-04
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT225564207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology