Provider Demographics
NPI:1356411565
Name:PAYNE, CASEY HARRIS (PA)
Entity type:Individual
Prefix:MRS
First Name:CASEY
Middle Name:HARRIS
Last Name:PAYNE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:CASEY
Other - Middle Name:MICHELLE
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1512 W KIRBY PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3822
Mailing Address - Country:US
Mailing Address - Phone:318-626-0287
Mailing Address - Fax:
Practice Address - Street 1:1541 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-626-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200090363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1805963Medicaid
TX336774001Medicaid
5BC11P895Medicare PIN
LAP00788058OtherRR MEDICARE
LAP00785452OtherRAILROAD MEDICARE
5BC11P895Medicare PIN