Healthcare Provider Details

I. General information

NPI: 1982171377
Provider Name (Legal Business Name): BRIANNE KATHLEEN CASSIDY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2018
Last Update Date: 10/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13690 E 14TH ST STE 230
SAN LEANDRO CA
94578-2584
US

IV. Provider business mailing address

13851 E 14TH ST STE 203
SAN LEANDRO CA
94578-2627
US

V. Phone/Fax

Practice location:
  • Phone: 510-614-9200
  • Fax:
Mailing address:
  • Phone: 510-614-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number55848
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: