Provider Demographics
NPI:1548231202
Name:CASSIDY, GREGORY CLARENCE (PA-C)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:CLARENCE
Last Name:CASSIDY
Suffix:
Gender:M
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2900 16TH ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-3510
Practice Address - Country:US
Practice Address - Phone:812-276-4358
Practice Address - Fax:812-275-1352
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-31
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601002063363A00000X
IN10003359A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant