Provider Demographics
NPI:1619105996
Name:BEDARD, CASEY L (PA)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:L
Last Name:BEDARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 LOCHAMY LANE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-2201
Mailing Address - Country:US
Mailing Address - Phone:904-860-9531
Mailing Address - Fax:
Practice Address - Street 1:1725 LOCHAMY LN
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-5478
Practice Address - Country:US
Practice Address - Phone:904-860-9531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013294363A00000X
FLPA9105446363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9105446OtherPA LICENSE