Provider Demographics
NPI:1063666824
Name:CASSIDY, PATRICK MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:MICHAEL
Last Name:CASSIDY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2695 ROCKY MOUNTAIN AVE
Mailing Address - Street 2:STE 150
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-4036
Mailing Address - Fax:970-490-4378
Practice Address - Street 1:350 LYCKMAN PL
Practice Address - Street 2:
Practice Address - City:FOUNTAIN
Practice Address - State:CO
Practice Address - Zip Code:80817-2861
Practice Address - Country:US
Practice Address - Phone:719-322-0777
Practice Address - Fax:719-322-0776
Is Sole Proprietor?:No
Enumeration Date:2008-11-06
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO2941363AM0700X
COPA.0002941363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO82629579Medicaid
COCO307467Medicare UPIN