Provider Demographics
NPI:1710201272
Name:DAVIS, CASEY LEIGH (PA-C)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:LEIGH
Last Name:DAVIS
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 1:2325 DOUGHERTY FERRY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-3356
Mailing Address - Country:US
Mailing Address - Phone:314-909-1359
Mailing Address - Fax:314-909-1370
Practice Address - Street 1:2325 DOUGHERTY FERRY RD STE 100
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63122-3356
Practice Address - Country:US
Practice Address - Phone:314-909-1359
Practice Address - Fax:314-909-1370
Is Sole Proprietor?:No
Enumeration Date:2010-03-26
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.003693207P00000X, 363A00000X
MO2011030386363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL1682040Medicare PIN