Provider Demographics
NPI:1851990832
Name:DOMINE, CASEY
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:DOMINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 SHEA CENTER DR STE 301
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80129-2277
Mailing Address - Country:US
Mailing Address - Phone:303-803-1005
Mailing Address - Fax:
Practice Address - Street 1:10099 RIDGEGATE PKWY STE 290
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124-5534
Practice Address - Country:US
Practice Address - Phone:303-803-1005
Practice Address - Fax:303-798-3248
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO363LP0200X363LP0200X
CA95015310363LP0200X
WAAP61457920363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics