Provider Demographics
NPI:1023399367
Name:CASEY, STEPHANIE ROBIN
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ROBIN
Last Name:CASEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10803 SE CHERRY BLOSSOM DRIVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216
Mailing Address - Country:US
Mailing Address - Phone:503-261-7200
Mailing Address - Fax:503-261-7249
Practice Address - Street 1:10803 SE CHERRY BLOSSOM DRIVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216
Practice Address - Country:US
Practice Address - Phone:503-261-7200
Practice Address - Fax:503-261-7249
Is Sole Proprietor?:No
Enumeration Date:2011-08-31
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO162682207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR276263Medicaid
ORDO162682OtherOREGON MEDICAL BOARD LICENSE