Healthcare Provider Details

I. General information

NPI: 1245503903
Provider Name (Legal Business Name): GEORGE F CASSIDY III PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2012
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 1014 27TH ST
FPO AA
76544
US

IV. Provider business mailing address

807 BOND ST
COPPERAS COVE TX
76522-3082
US

V. Phone/Fax

Practice location:
  • Phone: 254-288-1602
  • Fax:
Mailing address:
  • Phone: 210-870-9365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1102058
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA09724
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: