Provider Demographics
NPI:1942491188
Name:PRUNIER, KASEY L (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KASEY
Middle Name:L
Last Name:PRUNIER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KASEY
Other - Middle Name:L
Other - Last Name:VIOLETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:78 ATLANTIC PL
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2316
Mailing Address - Country:US
Mailing Address - Phone:207-661-6654
Mailing Address - Fax:207-842-7773
Practice Address - Street 1:123 ANDOVER RD
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:ME
Practice Address - Zip Code:04092-3848
Practice Address - Country:US
Practice Address - Phone:207-761-2200
Practice Address - Fax:207-761-2108
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA1102363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME000272001Medicare PIN