MEDICARE: CASSIDY SHIRLEY DMS, PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	10004610A	IN
2	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1598591489
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASSIDY SHIRLEY DMS, PA-C

Provider Business Mailing Address
First Line	:	6626 E 75TH ST STE 500
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250-2890
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8890 E 116TH ST STE 160
Second Line	:
City	:	FISHERS
State	:	IN
Zip	:	46038-2856
Country	:	US
Telephone Number	:	317-621-7030
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2024
Last Update Date	:	01/06/2026

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