Healthcare Provider Details

I. General information

NPI: 1649276429
Provider Name (Legal Business Name): JASON LEO CASSIDY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2005
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N 1ST ST
SPRINGFIELD IL
62781-2329
US

IV. Provider business mailing address

701 N 1ST ST
SPRINGFIELD IL
62781-0001
US

V. Phone/Fax

Practice location:
  • Phone: 217-788-3000
  • Fax:
Mailing address:
  • Phone: 217-788-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.020724
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2001022867
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: