Healthcare Provider Details

I. General information

NPI: 1811145733
Provider Name (Legal Business Name): CAROLYN FALLSTICK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2008
Last Update Date: 09/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E LANCASTER AVE
WYNNEWOOD PA
19096-3450
US

IV. Provider business mailing address

1735 MCNELIS DR
SOUTHAMPTON PA
18966-4051
US

V. Phone/Fax

Practice location:
  • Phone: 484-476-2285
  • Fax:
Mailing address:
  • Phone: 717-880-2972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA053526
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: