Provider Demographics
NPI:1902417389
Name:HALL, KASSANDRA NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:NICOLE
Last Name:HALL
Suffix:
Gender:F
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 1:525 ALEXANDRIA PIKE STE 320
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:KY
Mailing Address - Zip Code:41071-3243
Mailing Address - Country:US
Mailing Address - Phone:859-781-1310
Mailing Address - Fax:
Practice Address - Street 1:525 ALEXANDRIA PIKE STE 320
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:KY
Practice Address - Zip Code:41071-3243
Practice Address - Country:US
Practice Address - Phone:859-781-1310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
KYPA2655363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty