Healthcare Provider Details

I. General information

NPI: 1912376542
Provider Name (Legal Business Name): CASEY RATHBURN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2015
Last Update Date: 02/03/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 E COUNTY LINE RD
INDIANAPOLIS IN
46227-0963
US

IV. Provider business mailing address

250 N SHADELAND AVE STE 200
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 317-887-7805
  • Fax:
Mailing address:
  • Phone: 317-962-3834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10001957A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: