Provider Demographics
NPI:1245567775
Name:STAFFORD, KASSIE (PA)
Entity Type:Individual
Prefix:
First Name:KASSIE
Middle Name:
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11295 E. TAYLOR ROAD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4197
Mailing Address - Country:US
Mailing Address - Phone:228-864-3300
Mailing Address - Fax:228-864-3333
Practice Address - Street 1:11295 E TAYLOR RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4197
Practice Address - Country:US
Practice Address - Phone:228-864-3300
Practice Address - Fax:228-864-3333
Is Sole Proprietor?:No
Enumeration Date:2009-11-04
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAPA.200296363A00000X
MSPA00128363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant