Provider Demographics
NPI:1639856735
Name:WOOD, CASEY BINGHAM (PA-C)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:BINGHAM
Last Name:WOOD
Suffix:
Gender:M
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 1:6965 CUMBERLAND GAP PKWY
Mailing Address - Street 2:
Mailing Address - City:HARROGATE
Mailing Address - State:TN
Mailing Address - Zip Code:37752-8231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4300 E FLAMINGO AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-3138
Practice Address - Country:US
Practice Address - Phone:208-205-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-29
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-2628363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical