Provider Demographics
NPI:1033455530
Name:CASSIDY, MICKIE LYNN (LSA, CSFA)
Entity Type:Individual
Prefix:MS
First Name:MICKIE
Middle Name:LYNN
Last Name:CASSIDY
Suffix:
Gender:F
Credentials:LSA, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:701 JASE DR
Mailing Address - Street 2:
Mailing Address - City:COPPERAS COVE
Mailing Address - State:TX
Mailing Address - Zip Code:76522-4432
Mailing Address - Country:US
Mailing Address - Phone:512-743-8787
Mailing Address - Fax:
Practice Address - Street 1:1822 W BRAKER LN # 81603
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-3606
Practice Address - Country:US
Practice Address - Phone:512-973-9222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00649363AS0400X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical