Provider Demographics
NPI:1598951733
Name:ELLIOTT, CASEY DUSTIN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CASEY
Middle Name:DUSTIN
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 BOURLAND RD STE 170
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-3592
Mailing Address - Country:US
Mailing Address - Phone:817-741-2001
Mailing Address - Fax:817-741-2015
Practice Address - Street 1:100 BOURLAND RD STE 170
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3592
Practice Address - Country:US
Practice Address - Phone:817-741-2001
Practice Address - Fax:817-741-2015
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04628363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8K3656Medicare PIN
TX288030YKPWMedicare PIN
TX8K3517Medicare PIN