Provider Demographics
NPI:1689348229
Name:GONZALEZ, CASSIDY ELAINE
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:ELAINE
Last Name:GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CASSIDY
Other - Middle Name:ELAINE
Other - Last Name:CRAIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:116 N 700 E
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84606-3321
Mailing Address - Country:US
Mailing Address - Phone:435-770-2898
Mailing Address - Fax:
Practice Address - Street 1:116 N 700 E
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84606-3321
Practice Address - Country:US
Practice Address - Phone:435-770-2898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT124608261206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program