Provider Demographics
NPI:1659448215
Name:SANSOM, CASEY R (PA-C)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:R
Last Name:SANSOM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CASEY
Other - Middle Name:R
Other - Last Name:HANNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:420 HILLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:PA
Mailing Address - Zip Code:16127-1708
Mailing Address - Country:US
Mailing Address - Phone:724-458-4950
Mailing Address - Fax:724-458-4822
Practice Address - Street 1:420 HILLCREST AVE
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:PA
Practice Address - Zip Code:16127-1708
Practice Address - Country:US
Practice Address - Phone:724-458-4950
Practice Address - Fax:724-458-4822
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA000909363AM0700X
PAMA052529363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103205962Medicaid
PAQ16416Medicare UPIN