Provider Demographics
NPI:1336648369
Name:DEPEW, CASSIAH
Entity Type:Individual
Prefix:
First Name:CASSIAH
Middle Name:
Last Name:DEPEW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 AIRMOTIVE WAY
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-3201
Mailing Address - Country:US
Mailing Address - Phone:702-249-0837
Mailing Address - Fax:
Practice Address - Street 1:1325 AIRMOTIVE WAY
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-3201
Practice Address - Country:US
Practice Address - Phone:702-249-0837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV5445PCO-73747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV11941479549Medicaid
NV9005057011Medicaid
NV1295181055Medicaid
NV1114007101Medicaid
NV1427138338Medicaid
NV9005042153Medicaid
NV1548508591Medicaid