Provider Demographics
NPI:1861982944
Name:KERNAN, CASEY (DO)
Entity type:Individual
Prefix:DR
First Name:CASEY
Middle Name:
Last Name:KERNAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6968 NE ENETAI LN
Mailing Address - Street 2:
Mailing Address - City:SUQUAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98392-9766
Mailing Address - Country:US
Mailing Address - Phone:360-394-1350
Mailing Address - Fax:360-598-2709
Practice Address - Street 1:6968 NE ENETAI LN
Practice Address - Street 2:
Practice Address - City:SUQUAMISH
Practice Address - State:WA
Practice Address - Zip Code:98392-9766
Practice Address - Country:US
Practice Address - Phone:360-394-1350
Practice Address - Fax:360-598-2709
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP61093395207Q00000X, 207Q00000X
WA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2160220Medicaid