Basic Information
Provider Information | |||||||||
NPI: | 1558708644 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CASEY PROFESSIONAL HEALTH SERVICES PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1250 MANCHESTER CIR | ||||||||
Address2: |   | ||||||||
City: | FALLON | ||||||||
State: | NV | ||||||||
PostalCode: | 894063523 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7757504408 | ||||||||
FaxNumber: | 7754231158 | ||||||||
Practice Location | |||||||||
Address1: | 801 E WILLIAMS AVE | ||||||||
Address2: |   | ||||||||
City: | FALLON | ||||||||
State: | NV | ||||||||
PostalCode: | 894063052 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7024533799 | ||||||||
FaxNumber: | 7024535741 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/29/2013 | ||||||||
LastUpdateDate: | 07/08/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CASEY | ||||||||
AuthorizedOfficialFirstName: | AMANDA | ||||||||
AuthorizedOfficialMiddleName: | SUE | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 7757504408 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 13278 | NV | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 208M00000X | 13278 | NV | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |   |
ID Information
ID | Type | State | Issuer | Description | 13278 | 01 | NV | NV LIC | OTHER |