Provider Demographics
NPI:1760016356
Name:RUNTE, CASEY ROBERT
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:ROBERT
Last Name:RUNTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2046 ABALONE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-3802
Mailing Address - Country:US
Mailing Address - Phone:321-368-5427
Mailing Address - Fax:
Practice Address - Street 1:141 COCONUT DR
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-2607
Practice Address - Country:US
Practice Address - Phone:321-610-8939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1170542363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty