Basic Information
| Provider Information | |||||||||
| NPI: | 1205076015 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | CASEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EVENSON | ||||||||
| OtherFirstName: | CASEY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 670 9TH ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955216248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078268633 | ||||||||
| FaxNumber: | 7078268638 | ||||||||
| Practice Location | |||||||||
| Address1: | 2200 TYDD ST | ||||||||
| Address2: | |||||||||
| City: | EUREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955011284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7072697051 | ||||||||
| FaxNumber: | 7072697054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2009 | ||||||||
| LastUpdateDate: | 02/10/2017 | ||||||||
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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 | 363A00000X | 20196 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.