Provider Demographics
NPI:1881953602
Name:BROCK, CASEY SIMON (PA)
Entity type:Individual
Prefix:MR
First Name:CASEY
Middle Name:SIMON
Last Name:BROCK
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:2480 WHITE BEAR AVE N STE 104
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55109-4568
Mailing Address - Country:US
Mailing Address - Phone:612-444-3247
Mailing Address - Fax:612-888-9247
Practice Address - Street 1:920 E 1ST ST STE 201
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2215
Practice Address - Country:US
Practice Address - Phone:612-444-3247
Practice Address - Fax:612-888-4247
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2023-10-19
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Provider Licenses
StateLicense IDTaxonomies
WI5908-23363A00000X
TXPA09822363A00000X
FLPA9114121363A00000X
MN13273363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN18819533602Medicaid