Provider Demographics
NPI:1699324707
Name:SALCEDO, CASEY
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:SALCEDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 DOWDY RD STE 204
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-5700
Mailing Address - Country:US
Mailing Address - Phone:706-621-7575
Mailing Address - Fax:833-305-0340
Practice Address - Street 1:132 FRANKLIN SPRINGS ST STE A
Practice Address - Street 2:
Practice Address - City:ROYSTON
Practice Address - State:GA
Practice Address - Zip Code:30662-4134
Practice Address - Country:US
Practice Address - Phone:706-621-7575
Practice Address - Fax:833-305-0340
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN184724363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003232886ROtherMEDICAID
GARN184724OtherPROFESSIONAL LICENSE
GA1699324707OtherNPI
GAG17368BOtherMEDICARE PROVIDER ID