Provider Demographics
NPI:1649276429
Name:CASSIDY, JASON LEO (CRNA)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:LEO
Last Name:CASSIDY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62781-0001
Mailing Address - Country:US
Mailing Address - Phone:217-788-3000
Mailing Address - Fax:
Practice Address - Street 1:701 N 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62781-2329
Practice Address - Country:US
Practice Address - Phone:217-788-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-25
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.020724367500000X
MO2001022867367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209020724OtherCRNA LICENSE
MO919107201Medicaid
MOP00133340OtherRAILROAD MEDICARE