Provider Demographics
NPI:1568005122
Name:CASEY, ERIN MARIE
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:MARIE
Last Name:CASEY
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 1:454 BROADWAY FL 3
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-3034
Mailing Address - Country:US
Mailing Address - Phone:781-485-8222
Mailing Address - Fax:781-485-8220
Practice Address - Street 1:454 BROADWAY FL 3
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-3034
Practice Address - Country:US
Practice Address - Phone:781-485-8222
Practice Address - Fax:781-485-8220
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-25
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58210363A00000X
390200000X
MA8490363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty