Provider Demographics
NPI:1609222827
Name:KOONTZ, CASSANDRA (NP)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:KOONTZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 E FLORENCE BLVD
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-5303
Mailing Address - Country:US
Mailing Address - Phone:520-381-6648
Mailing Address - Fax:520-381-6068
Practice Address - Street 1:1800 E FLORENCE BLVD
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-5303
Practice Address - Country:US
Practice Address - Phone:520-381-6648
Practice Address - Fax:520-381-6068
Is Sole Proprietor?:No
Enumeration Date:2016-05-06
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP8492363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner