Provider Demographics
NPI:1083071732
Name:SHIELDS, CASEY
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:SHIELDS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5801 SWAN WALK
Mailing Address - Street 2:
Mailing Address - City:SUGAR HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30518-2172
Mailing Address - Country:US
Mailing Address - Phone:678-227-3855
Mailing Address - Fax:
Practice Address - Street 1:5673 PEACHTREE DUNWOODY RD
Practice Address - Street 2:STE 330
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1731
Practice Address - Country:US
Practice Address - Phone:404-459-0002
Practice Address - Fax:404-459-0003
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN230217363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003175687FMedicaid
GA003175687DMedicaid
GA202I509173Medicare PIN