Basic Information
| Provider Information | |||||||||
| NPI: | 1568798932 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASSIDY | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 155 CRYSTAL RUN RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109414028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457036999 | ||||||||
| FaxNumber: | 8457036297 | ||||||||
| Practice Location | |||||||||
| Address1: | 95 CRYSTAL RUN RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109417001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457036999 | ||||||||
| FaxNumber: | 8457036297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2009 | ||||||||
| LastUpdateDate: | 08/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 013649 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 013649 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 03191206 | 05 | NY | MEDICAID |