Basic Information
Provider Information | |||||||||
NPI: | 1154313138 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CASEY | ||||||||
FirstName: | ELISA | ||||||||
MiddleName: | HANSON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HANSON | ||||||||
OtherFirstName: | ELISA | ||||||||
OtherMiddleName: | BETH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | ARNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1965 CAPITAL CIR NE STE 200 | ||||||||
Address2: |   | ||||||||
City: | TALLAHASSEE | ||||||||
State: | FL | ||||||||
PostalCode: | 323088402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8506562006 | ||||||||
FaxNumber: | 8506562820 | ||||||||
Practice Location | |||||||||
Address1: | 1965 CAPITAL CIR NE STE 200 | ||||||||
Address2: |   | ||||||||
City: | TALLAHASSEE | ||||||||
State: | FL | ||||||||
PostalCode: | 323088402 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8506562006 | ||||||||
FaxNumber: | 8506562820 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/17/2005 | ||||||||
LastUpdateDate: | 04/15/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP2749512 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 307174000 | 05 | FL |   | MEDICAID | Y082J | 01 | FL | BCBS OF FLORIDA | OTHER |