Provider Demographics
NPI:1437860186
Name:NORMAN, KASEY RYAN (STUDENT)
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:RYAN
Last Name:NORMAN
Suffix:
Gender:M
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8281 GOLD COAST DR UNIT 5
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-3686
Mailing Address - Country:US
Mailing Address - Phone:325-665-9403
Mailing Address - Fax:
Practice Address - Street 1:8281 GOLD COAST DR UNIT 5
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-3686
Practice Address - Country:US
Practice Address - Phone:325-665-9403
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-13
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1710I1002X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program