Healthcare Provider Details

I. General information

NPI: 1972339166
Provider Name (Legal Business Name): CASSIDY JAE SOPER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CASSIDY JAE HANSON

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 09/18/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3409 LUDINGTON ST STE 100
ESCANABA MI
49829-4213
US

IV. Provider business mailing address

5737 S OAK PARK DRIVE 17.5
WELLS MI
49894
US

V. Phone/Fax

Practice location:
  • Phone: 906-233-4276
  • Fax: 906-786-0660
Mailing address:
  • Phone: 906-233-4276
  • Fax: 906-786-0660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601012721
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: