Provider Demographics
NPI:1770227472
Name:VERBANAZ, CASEY MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:MARIE
Last Name:VERBANAZ
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 1:71 OLD COUNTRY CT
Mailing Address - Street 2:
Mailing Address - City:LAKE SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-5845
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:615 S NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8221
Practice Address - Country:US
Practice Address - Phone:314-251-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021051040363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant