Provider Demographics
NPI:1669723391
Name:JOHNSON, CASSIDY BLAIRE (PA-C)
Entity type:Individual
Prefix:
First Name:CASSIDY
Middle Name:BLAIRE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CASSIDY
Other - Middle Name:BLAIRE
Other - Last Name:KEISER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 74647
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44194-4647
Mailing Address - Country:US
Mailing Address - Phone:440-879-0081
Mailing Address - Fax:440-879-0084
Practice Address - Street 1:6780 MAYFIELD RD
Practice Address - Street 2:
Practice Address - City:MAYFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44124-2203
Practice Address - Country:US
Practice Address - Phone:440-449-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50003589363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical