Provider Demographics
NPI:1972753374
Name:GERNON, CASEY NICOLE (PA)
Entity Type:Individual
Prefix:MS
First Name:CASEY
Middle Name:NICOLE
Last Name:GERNON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:CASEY
Other - Middle Name:NICOLE
Other - Last Name:HEWITT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:14011 PARK AVE
Mailing Address - Street 2:DEPT. OF FAMILY MEDICINE
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392
Mailing Address - Country:US
Mailing Address - Phone:760-843-2423
Mailing Address - Fax:
Practice Address - Street 1:14011 PARK AVE
Practice Address - Street 2:DEPT. OF FAMILY MEDICINE
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392
Practice Address - Country:US
Practice Address - Phone:760-843-2423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CAPA20023363A00000X
CA1085196363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant