Provider Demographics
NPI:1154665909
Name:ILYASOVA, CASSIE BREANNA (PA-C)
Entity Type:Individual
Prefix:
First Name:CASSIE
Middle Name:BREANNA
Last Name:ILYASOVA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:504 REDMOND RD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1416
Practice Address - Country:US
Practice Address - Phone:762-235-3130
Practice Address - Fax:706-290-2721
Is Sole Proprietor?:No
Enumeration Date:2012-11-17
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA7137363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant