Provider Demographics
NPI:1386138568
Name:DESHAMBO, CASEY GERALD
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:GERALD
Last Name:DESHAMBO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 MEMORIAL DR APT 207
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-5309
Mailing Address - Country:US
Mailing Address - Phone:906-399-6491
Mailing Address - Fax:
Practice Address - Street 1:2100 MEMORIAL DR APT 207
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-5309
Practice Address - Country:US
Practice Address - Phone:906-399-6491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program