Healthcare Provider Details

I. General information

NPI: 1881223022
Provider Name (Legal Business Name): SHELLY J KASIK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 10/30/2023
Certification Date: 04/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1554 WESLEY WAY
LANCASTER OH
43130
US

IV. Provider business mailing address

1629 CLOVERDALE DR
LANCASTER OH
43130-8109
US

V. Phone/Fax

Practice location:
  • Phone: 740-687-6386
  • Fax: 740-687-1388
Mailing address:
  • Phone: 810-531-7328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.006413RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: