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General NPI Number Information
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NPI Number | 1245567775
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Entity Type | Individual
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Provider Name | KASSIE STAFFORD PA
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Gender | Female
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Dates
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Enumeration Date | 11/04/2009
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Last Update Date | 10/18/2024
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Provider Practice Location Address
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Address Line | 116 MENGE AVE APT A
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City | PASS CHRISTIAN
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State | MS
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Zip | 39571-4738
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Country | US
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Telephone | 228-586-9565
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Fax | 228-864-3333
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Provider Business Mailing Address
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Address Line | 11295 E. TAYLOR ROAD
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City | GULFPORT
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State | MS
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Zip | 39503-4197
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Country | US
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Telephone | 228-864-3300
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Fax | 228-864-3333
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA.200296
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA00128
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License Number State | MS
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