Healthcare Provider Details

I. General information

NPI: 1528720646
Provider Name (Legal Business Name): JOSEPH AUSTIN CASSIDY APRN, CPNP-PC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2021
Last Update Date: 10/25/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1912 W 930 N
PLEASANT GROVE UT
84062-4104
US

IV. Provider business mailing address

1912 W 930 N
PLEASANT GROVE UT
84062-4104
US

V. Phone/Fax

Practice location:
  • Phone: 803-367-1480
  • Fax:
Mailing address:
  • Phone: 803-367-1480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number12445460-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number12445460-4405
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number12445460-3102
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number248472
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: