Provider Demographics
NPI:1295732428
Name:CASSIDY, SUSAN (ANP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:CASSIDY
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1951 N WILMOT RD
Mailing Address - Street 2:BLDG 4
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-8000
Mailing Address - Country:US
Mailing Address - Phone:520-318-1114
Mailing Address - Fax:520-318-4693
Practice Address - Street 1:1951 N WILMOT RD
Practice Address - Street 2:BLDG 4
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-8000
Practice Address - Country:US
Practice Address - Phone:520-318-1114
Practice Address - Fax:520-318-4693
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN045317164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP18014Medicare UPIN
AZ63538Medicare ID - Type Unspecified