Healthcare Provider Details

I. General information

NPI: 1780469619
Provider Name (Legal Business Name): CASSIDY KORSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2023
Last Update Date: 10/04/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE
LANSING MI
48912-1811
US

IV. Provider business mailing address

2558 E ASHBY RD
MIDLAND MI
48640-8904
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-1000
  • Fax:
Mailing address:
  • Phone: 989-941-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601012014
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: