Provider Demographics
NPI:1952300535
Name:PRESTON CASAVANT, SHAWN NICOLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHAWN
Middle Name:NICOLE
Last Name:PRESTON CASAVANT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:SHAWN
Other - Middle Name:NICOLE
Other - Last Name:PRESTON CASAVANT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:1900 DON WICKHAM DRIVE
Mailing Address - Street 2:STE 120
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1947
Mailing Address - Country:US
Mailing Address - Phone:352-241-7050
Mailing Address - Fax:352-241-7035
Practice Address - Street 1:1900 DON WICKHAM DRIVE
Practice Address - Street 2:STE 120
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1947
Practice Address - Country:US
Practice Address - Phone:352-241-7050
Practice Address - Fax:352-241-7035
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3403363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291263500Medicaid
FL291263500Medicaid
FLE7775ZMedicare ID - Type Unspecified