Provider Demographics
NPI:1083087944
Name:BROADHEAD, CASSIE K (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CASSIE
Middle Name:K
Last Name:BROADHEAD
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:1055 N 500 W
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:97 PROFESSIONAL WAY
Practice Address - Street 2:STE 2
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-1614
Practice Address - Country:US
Practice Address - Phone:801-465-4896
Practice Address - Fax:801-465-4107
Is Sole Proprietor?:No
Enumeration Date:2015-11-01
Last Update Date:2015-11-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WYPT654363A00000X
UT9537931-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant