Healthcare Provider Details

I. General information

NPI: 1760016356
Provider Name (Legal Business Name): CASEY ROBERT RUNTE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2020
Last Update Date: 02/24/2020
Certification Date: 02/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 COCONUT DR
INDIALANTIC FL
32903-2607
US

IV. Provider business mailing address

2046 ABALONE AVE
INDIALANTIC FL
32903-3802
US

V. Phone/Fax

Practice location:
  • Phone: 321-610-8939
  • Fax:
Mailing address:
  • Phone: 321-368-5427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1170542
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: