Provider Demographics
NPI:1083294201
Name:JOHN, CASEY (PA-C)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1344 TOWSON ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-5324
Mailing Address - Country:US
Mailing Address - Phone:304-389-4131
Mailing Address - Fax:
Practice Address - Street 1:2014 S TOLLGATE RD STE 212
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-5904
Practice Address - Country:US
Practice Address - Phone:410-849-4212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-12
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0007837363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant