Provider Demographics
NPI:1063739381
Name:PORTILLO, CASEY ANNE (PA - C)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:ANNE
Last Name:PORTILLO
Suffix:
Gender:F
Credentials:PA - C
Other - Prefix:
Other - First Name:CASEY
Other - Middle Name:ANNE
Other - Last Name:ADAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:8201 MEMORIAL LN
Mailing Address - Street 2:#2022
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024-2253
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1935 MEDICAL DISTRICT DR
Practice Address - Street 2:PAVILLION 3RD FLOOR
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7701
Practice Address - Country:US
Practice Address - Phone:214-456-1798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-26
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03803363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant