Provider Demographics
NPI:1013576123
Name:DOTSON, CASSANDRA
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:DOTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2212 FREDERICK DOUGLAS BLVD
Mailing Address - Street 2:APT 3C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026
Mailing Address - Country:US
Mailing Address - Phone:402-909-3599
Mailing Address - Fax:
Practice Address - Street 1:560 W 168TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3917
Practice Address - Country:US
Practice Address - Phone:212-305-5756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY732042163W00000X
MDAC004111367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse