Basic Information
| Provider Information | |||||||||
| NPI: | 1083071732 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHIELDS | ||||||||
| FirstName: | CASEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5801 SWAN WALK | ||||||||
| Address2: | |||||||||
| City: | SUGAR HILL | ||||||||
| State: | GA | ||||||||
| PostalCode: | 305182172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6782273855 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5673 PEACHTREE DUNWOODY RD | ||||||||
| Address2: | STE 330 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303421731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4044590002 | ||||||||
| FaxNumber: | 4044590003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2016 | ||||||||
| LastUpdateDate: | 12/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN230217 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 003175687F | 05 | GA | MEDICAID | 003175687D | 05 | GA | MEDICAID |