Healthcare Provider Details

I. General information

NPI: 1245567775
Provider Name (Legal Business Name): KASSIE STAFFORD PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2009
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 MENGE AVE APT A
PASS CHRISTIAN MS
39571-4738
US

IV. Provider business mailing address

11295 E. TAYLOR ROAD
GULFPORT MS
39503-4197
US

V. Phone/Fax

Practice location:
  • Phone: 228-586-9565
  • Fax: 228-864-3333
Mailing address:
  • Phone: 228-864-3300
  • Fax: 228-864-3333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.200296
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00128
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: