Provider Demographics
NPI:1790790111
Name:BALLENTINE, CASSITY WRIGHT (PA-C)
Entity Type:Individual
Prefix:
First Name:CASSITY
Middle Name:WRIGHT
Last Name:BALLENTINE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CASSITY
Other - Middle Name:
Other - Last Name:WRIGHT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9242 TARGHEE DR
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-6357
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5292 COLLEGE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84123-2958
Practice Address - Country:US
Practice Address - Phone:385-232-4457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7382912-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant