Provider Demographics
NPI:1336214782
Name:CARUSO, KELLY MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:CARUSO
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 1:20060 GOVERNORS DR STE 300
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-1099
Mailing Address - Country:US
Mailing Address - Phone:708-283-2600
Mailing Address - Fax:708-833-7248
Practice Address - Street 1:20060 GOVERNORS DR STE 300
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1099
Practice Address - Country:US
Practice Address - Phone:708-283-2600
Practice Address - Fax:708-833-7248
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-002871363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant