Provider Demographics
NPI:1235684838
Name:KOLP, CASEY (PA-C)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:KOLP
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 1:23230 DETOUR ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48082-2028
Mailing Address - Country:US
Mailing Address - Phone:586-306-1881
Mailing Address - Fax:
Practice Address - Street 1:4160 JOHN R ST STE 930
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2017
Practice Address - Country:US
Practice Address - Phone:313-966-5007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007864363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant