Provider Demographics
NPI:1891890166
Name:CASSIDY, JOHN F IV (PA-C)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:F
Last Name:CASSIDY
Suffix:IV
Gender:M
Credentials:PA-C
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 1599
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04402-1599
Mailing Address - Country:US
Mailing Address - Phone:207-945-5247
Mailing Address - Fax:207-947-0435
Practice Address - Street 1:34 SUMMER ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6446
Practice Address - Country:US
Practice Address - Phone:207-992-2636
Practice Address - Fax:207-992-2638
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA389363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME259290099Medicaid
MEMM9086OtherMEDICARE GROUP NUMBER
ME259290099Medicaid