Provider Demographics
NPI:1962885020
Name:BOWLES, CASEY RAE (PA-C)
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:RAE
Last Name:BOWLES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4615 HUNTRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-8510
Mailing Address - Country:US
Mailing Address - Phone:540-977-0900
Mailing Address - Fax:540-977-0550
Practice Address - Street 1:4615 HUNTRIDGE RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-8510
Practice Address - Country:US
Practice Address - Phone:540-977-0900
Practice Address - Fax:540-977-0550
Is Sole Proprietor?:No
Enumeration Date:2015-07-07
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004997363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1962885020Medicaid
VA1962885020Medicaid