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General NPI Number Information
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NPI Number | 1700604865
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Entity Type | Individual
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Provider Name | CASEY SHANNON MULLIGAN PA-C
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Gender | Female
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Dates
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Enumeration Date | 09/27/2024
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Last Update Date | 09/29/2024
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Provider Practice Location Address
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Address Line | 128 E MAIN ST
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City | NANTICOKE
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State | PA
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Zip | 18634-1604
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Country | US
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Telephone | 570-258-1304
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Fax |
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Provider Business Mailing Address
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Address Line | 26 MARTIN ST
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City | HANOVER TOWNSHIP
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State | PA
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Zip | 18706-1010
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Country | US
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Telephone | 570-899-4522
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | MA066065
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License Number State | PA
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