Provider Demographics
NPI:1487214359
Name:WADSWORTH, CASEY
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:WADSWORTH
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 1:45 SYCAMORE AVE APT 1218
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-6736
Mailing Address - Country:US
Mailing Address - Phone:843-517-2879
Mailing Address - Fax:
Practice Address - Street 1:135 CANNON ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-8909
Practice Address - Country:US
Practice Address - Phone:843-792-7108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL82606207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCLL82606OtherSC LICENSE NUMBER