Healthcare Provider Details

I. General information

NPI: 1891890166
Provider Name (Legal Business Name): JOHN F CASSIDY IV PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 04/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 SUMMER ST
BANGOR ME
04401-6446
US

IV. Provider business mailing address

PO BOX 1599
BANGOR ME
04402-1599
US

V. Phone/Fax

Practice location:
  • Phone: 207-992-2636
  • Fax: 207-992-2638
Mailing address:
  • Phone: 207-945-5247
  • Fax: 207-947-0435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA389
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: