=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427536895
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASEY LYNN WARD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2018
-----------------------------------------------------
Last Update Date | 11/26/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 MEDICAL DR
-----------------------------------------------------
City | PORT JEFFERSON STATION
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11776-1601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-364-9119
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24 CARNEGIE DR
-----------------------------------------------------
City | SMITHTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11787-2029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------