Provider Demographics
NPI:1578572772
Name:CASEY, BETHANY FOOSE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:BETHANY
Middle Name:FOOSE
Last Name:CASEY
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 1:3369 COLONIAL AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3739
Mailing Address - Country:US
Mailing Address - Phone:540-772-0555
Mailing Address - Fax:540-772-1360
Practice Address - Street 1:3369 COLONIAL AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018
Practice Address - Country:US
Practice Address - Phone:540-772-0555
Practice Address - Fax:540-772-1360
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110003301363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1073713OtherBRICKSTREET-WV COMP
WV6013154600OtherBLACK LUNG
WV1073713OtherBRICKSTREET-WV COMP
WVBOPA31831Medicare PIN
WVP00720950Medicare PIN