Provider Demographics
NPI:1811028145
Name:WARDEN DUTTON, CASEY DAWN
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:DAWN
Last Name:WARDEN DUTTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CASEY
Other - Middle Name:
Other - Last Name:DUTTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5770 SOUTH WOODCREST DRIVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85746-3245
Mailing Address - Country:US
Mailing Address - Phone:520-294-1179
Mailing Address - Fax:520-750-0056
Practice Address - Street 1:5770 S. WOODCREST DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85746-3245
Practice Address - Country:US
Practice Address - Phone:520-294-1179
Practice Address - Fax:520-750-0056
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10037171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ945107Medicaid