Provider Demographics
NPI:1265403844
Name:MCILVAIN, LYNNE (RPAC)
Entity type:Individual
Prefix:
First Name:LYNNE
Middle Name:
Last Name:MCILVAIN
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5794 WIDEWATERS PKWY
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-1845
Mailing Address - Country:US
Mailing Address - Phone:315-422-1513
Mailing Address - Fax:315-422-5890
Practice Address - Street 1:5794 WIDEWATERS PKWY
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-1845
Practice Address - Country:US
Practice Address - Phone:315-422-1513
Practice Address - Fax:315-422-5890
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
001720363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01286680Medicaid
P28177Medicare UPIN
NYCC4872Medicare ID - Type Unspecified