Provider Demographics
NPI:1649949082
Name:EBACH, CASSIDY
Entity type:Individual
Prefix:
First Name:CASSIDY
Middle Name:
Last Name:EBACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22510 MOORGATE ST
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-3769
Mailing Address - Country:US
Mailing Address - Phone:124-892-4580
Mailing Address - Fax:
Practice Address - Street 1:36622 FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1900
Practice Address - Country:US
Practice Address - Phone:734-266-3349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010644363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant