Provider Demographics
NPI:1205063252
Name:TAYLOR-RACINELLI, CASEY AMANDA (PA-C)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:AMANDA
Last Name:TAYLOR-RACINELLI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CASEY
Other - Middle Name:AMANDA
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1061 HARMON AVENUE
Mailing Address - Street 2:SUITE 1D03
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5674
Mailing Address - Country:US
Mailing Address - Phone:912-435-5476
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVENUE
Practice Address - Street 2:SUITE 1D03
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5674
Practice Address - Country:US
Practice Address - Phone:912-435-5476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1144363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant