Provider Demographics
NPI:1851388367
Name:CASSON, PAMELA WALLACE (MD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:WALLACE
Last Name:CASSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:PAMELA
Other - Middle Name:JANE
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1465 KELLY JOHNSON BLVD
Mailing Address - Street 2:SUITE 220
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3955
Mailing Address - Country:US
Mailing Address - Phone:719-265-1050
Mailing Address - Fax:719-265-2503
Practice Address - Street 1:1465 KELLY JOHNSON BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3955
Practice Address - Country:US
Practice Address - Phone:719-265-1050
Practice Address - Fax:719-265-2503
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41888208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO85487210Medicaid