Provider Demographics
NPI:1487627899
Name:CASSIDY, JOHN E (PAC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:CASSIDY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ELM ST
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:VT
Mailing Address - Zip Code:05149-1301
Mailing Address - Country:US
Mailing Address - Phone:802-228-8867
Mailing Address - Fax:
Practice Address - Street 1:1 ELM ST
Practice Address - Street 2:
Practice Address - City:LUDLOW
Practice Address - State:VT
Practice Address - Zip Code:05149-1301
Practice Address - Country:US
Practice Address - Phone:802-228-8867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055-0030640363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT2000912Medicaid
VTAP0519Medicare ID - Type Unspecified
VT2000912Medicaid