Provider Demographics
NPI:1003151028
Name:BLACK, CASEY R (NP)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:R
Last Name:BLACK
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:125 EAGLE SPRING DR
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6328
Mailing Address - Country:US
Mailing Address - Phone:770-213-3366
Mailing Address - Fax:404-962-6943
Practice Address - Street 1:125 EAGLE SPRING DR
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6328
Practice Address - Country:US
Practice Address - Phone:770-213-3366
Practice Address - Fax:404-962-6943
Is Sole Proprietor?:No
Enumeration Date:2012-12-03
Last Update Date:2017-05-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GARN146749363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I501861Medicare PIN