Provider Demographics
NPI:1205076015
Name:KELLY, CASEY (PA)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CASEY
Other - Middle Name:
Other - Last Name:EVENSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:670 9TH ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-6248
Mailing Address - Country:US
Mailing Address - Phone:707-826-8633
Mailing Address - Fax:707-826-8638
Practice Address - Street 1:2200 TYDD ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-1284
Practice Address - Country:US
Practice Address - Phone:707-269-7051
Practice Address - Fax:707-269-7054
Is Sole Proprietor?:No
Enumeration Date:2009-03-06
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20196363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant