Provider Demographics
NPI:1700604865
Name:MULLIGAN, CASEY SHANNON (PA-C)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:SHANNON
Last Name:MULLIGAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:HANOVER TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:18706-1010
Mailing Address - Country:US
Mailing Address - Phone:570-899-4522
Mailing Address - Fax:
Practice Address - Street 1:128 E MAIN ST
Practice Address - Street 2:
Practice Address - City:NANTICOKE
Practice Address - State:PA
Practice Address - Zip Code:18634-1604
Practice Address - Country:US
Practice Address - Phone:570-258-1304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-27
Last Update Date:2024-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA066065363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical