Healthcare Provider Details

I. General information

NPI: 1265476964
Provider Name (Legal Business Name): CASSANDRA BLACKWELL P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18880 CHERRY VALLEY BLVD.
TUOLUMNE CA
95379
US

IV. Provider business mailing address

18880 CHERRY VALLEY BLVD.
TUOLUMNE CA
95379
US

V. Phone/Fax

Practice location:
  • Phone: 209-928-5400
  • Fax: 209-928-5412
Mailing address:
  • Phone: 209-928-5400
  • Fax: 209-928-5412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15883
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: