Provider Demographics
NPI:1215553631
Name:HAMILTON, KASSIDY
Entity Type:Individual
Prefix:
First Name:KASSIDY
Middle Name:
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KASSIDY
Other - Middle Name:
Other - Last Name:GIERTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2101 N 14TH ST STE 114
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-1807
Mailing Address - Country:US
Mailing Address - Phone:580-762-2366
Mailing Address - Fax:
Practice Address - Street 1:9003 N GARNETT RD
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-4495
Practice Address - Country:US
Practice Address - Phone:918-272-2882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant