Provider Demographics
NPI:1265458459
Name:HUMPHRIES, CASEY L (CRNA)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:L
Last Name:HUMPHRIES
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 LAKE CREST DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9564
Mailing Address - Country:US
Mailing Address - Phone:662-255-4512
Mailing Address - Fax:870-933-7161
Practice Address - Street 1:4800 E JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72405-8413
Practice Address - Country:US
Practice Address - Phone:662-377-4394
Practice Address - Fax:662-377-7045
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA810167367500000X
ARC001250367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01159742Medicaid
AL009936767OtherMEDICAID
MS430002089Medicare ID - Type Unspecified
P17861Medicare UPIN