Basic Information
| Provider Information | |||||||||
| NPI: | 1679881486 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASELLA | ||||||||
| FirstName: | CARLYLE | ||||||||
| MiddleName: | FAIRFAX HOOFF | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CASELLA | ||||||||
| OtherFirstName: | CARLYLE | ||||||||
| OtherMiddleName: | HOOFF | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 14010 SMOKETOWN RD | ||||||||
| Address2: | SUITE 117 | ||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221924722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035800181 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14010 SMOKETOWN RD | ||||||||
| Address2: | SUITE 117 | ||||||||
| City: | WOODBRIDGE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221924722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7035800181 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2010 | ||||||||
| LastUpdateDate: | 04/13/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA0000002616 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0110005347 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.