Provider Demographics
NPI:1790454775
Name:HARDTKE, KASSANDRA MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:MICHELLE
Last Name:HARDTKE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KASSANDRA
Other - Middle Name:MICHELLE
Other - Last Name:KERNAGIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:18444 N 25TH AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-1266
Mailing Address - Country:US
Mailing Address - Phone:669-742-6738
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:1500 S DOBSON RD STE 202
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-4724
Practice Address - Country:US
Practice Address - Phone:866-974-2673
Practice Address - Fax:866-939-2673
Is Sole Proprietor?:No
Enumeration Date:2021-09-13
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003485A363A00000X
AZ9845363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant