Healthcare Provider Details

I. General information

NPI: 1679310098
Provider Name (Legal Business Name): CASSIDY KOCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2024
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 BAY ST STE 201
TAUNTON MA
02780-1085
US

IV. Provider business mailing address

2005 BAY ST STE 201
TAUNTON MA
02780-1085
US

V. Phone/Fax

Practice location:
  • Phone: 508-822-2266
  • Fax: 508-823-5689
Mailing address:
  • Phone: 508-822-2266
  • Fax: 603-319-8308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: