Provider Demographics
NPI:1629322524
Name:CHEVALIER, CASEY JO (PA-C)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:JO
Last Name:CHEVALIER
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 1:3415 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25304-1334
Mailing Address - Country:US
Mailing Address - Phone:304-388-8380
Mailing Address - Fax:304-388-8395
Practice Address - Street 1:116 HILLS PLZ
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25387-2438
Practice Address - Country:US
Practice Address - Phone:304-720-4466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-31
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01678363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1629322524Medicaid