Provider Demographics
NPI:1639639636
Name:NUNEZ, KASSANDRA (PA-C)
Entity type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:
Last Name:NUNEZ
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 1:4001 N CENTRAL AVE APT 242
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2140
Mailing Address - Country:US
Mailing Address - Phone:201-835-8788
Mailing Address - Fax:
Practice Address - Street 1:926 E MCDOWELL RD STE 134
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2521
Practice Address - Country:US
Practice Address - Phone:602-288-0777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ7963363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
1175067OtherNATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS
AZ7963OtherARIZONA REGULATORY BOARD OF PHYSICIAN ASSISTANTS