Provider Demographics
NPI:1629229539
Name:CASSIDY, RANDALL L (CNP)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:L
Last Name:CASSIDY
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 636643
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6643
Mailing Address - Country:US
Mailing Address - Phone:440-366-2239
Mailing Address - Fax:440-365-1366
Practice Address - Street 1:1120 E BROAD ST
Practice Address - Street 2:
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-6306
Practice Address - Country:US
Practice Address - Phone:440-365-2239
Practice Address - Fax:440-365-1366
Is Sole Proprietor?:No
Enumeration Date:2008-10-09
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH258009363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0236248Medicaid
OH11937343OtherCAQH
OH2914234Medicaid
OH3025372Medicaid
OH3025372Medicaid
OHNP83012Medicare PIN
OH0236248Medicaid
OH11937343OtherCAQH