Basic Information
| Provider Information | |||||||||
| NPI: | 1891890166 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASSIDY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | IV | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1599 | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044021599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079455247 | ||||||||
| FaxNumber: | 2079470435 | ||||||||
| Practice Location | |||||||||
| Address1: | 34 SUMMER ST | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044016446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079922636 | ||||||||
| FaxNumber: | 2079922638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2006 | ||||||||
| LastUpdateDate: | 04/02/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA389 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 259290099 | 05 | ME | MEDICAID | MM9086 | 01 | ME | MEDICARE GROUP NUMBER | OTHER |