MEDICARE: DR. CASEY SHILLAM RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WG0600X	Gerontology Registered Nurse	200242028	OR

General Provider Information

NPI Number	:	1598253510
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CASEY SHILLAM RN

Provider Business Mailing Address
First Line	:	5000 N WILLAMETTE BLVD # 153
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97203-5798
Country	:	US
Telephone Number	:	503-943-8143
Fax Number	:

Provider Business Practice Location Address
First Line	:	5000 N WILLAMETTE BLVD # 153
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97203-5798
Country	:	US
Telephone Number	:	503-943-8143
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2018
Last Update Date	:	04/25/2018

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