=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972339166
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASSIDY JAE HANSON PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2024
-----------------------------------------------------
Last Update Date | 09/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4289 E MAPLE RIDGE 37TH RD
-----------------------------------------------------
City | ROCK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49880-9582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-420-4759
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 545 COUNTY ROAD HQ
-----------------------------------------------------
City | MARQUETTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49855-8855
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-273-0072
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 5601012721
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------