Basic Information
| Provider Information | |||||||||
| NPI: | 1154642700 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASEY | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PHD, ANP, CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | DIVISION OF INTERNAL MEDICINE, L475 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034948562 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3181 SW SAM JACKSON PARK RD | ||||||||
| Address2: | DIVISION OF INTERNAL MEDICINE, L475 | ||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972393011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034948562 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2010 | ||||||||
| LastUpdateDate: | 12/03/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 201050070NP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 364S00000X | 200770014CNS | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
ID Information
| ID | Type | State | Issuer | Description | ANP736 | 01 | OR | STATE OF OREGON WORKERS' COMPENSATION NUMBER | OTHER |