Provider Demographics
NPI:1457565392
Name:WILLIAMSON, CASSANDRA LYNN (PA)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:LYNN
Last Name:WILLIAMSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4340 CLYO RD STE 200
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-7000
Mailing Address - Country:US
Mailing Address - Phone:937-396-2602
Mailing Address - Fax:937-395-3682
Practice Address - Street 1:4340 CLYO RD STE 200
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-7000
Practice Address - Country:US
Practice Address - Phone:937-534-7330
Practice Address - Fax:937-395-3682
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002157363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0247616Medicaid