Provider Demographics
NPI:1013167212
Name:HUMPHREY, CASEY JOSEPH (PA)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:JOSEPH
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4412 KELL BLVD
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76309-4719
Mailing Address - Country:US
Mailing Address - Phone:940-696-0011
Mailing Address - Fax:940-696-2248
Practice Address - Street 1:4412 KELL BLVD
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76309-4719
Practice Address - Country:US
Practice Address - Phone:940-696-0011
Practice Address - Fax:940-696-2248
Is Sole Proprietor?:No
Enumeration Date:2008-09-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01152363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant