Healthcare Provider Details

I. General information

NPI: 1003535733
Provider Name (Legal Business Name): CASSIDY DIEDE AA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 4TH ST STOP 8182
LUBBOCK TX
79430-8182
US

IV. Provider business mailing address

PO BOX 764
MEAD CO
80542-0764
US

V. Phone/Fax

Practice location:
  • Phone: 806-743-2981
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number32698256
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: