Provider Demographics
NPI:1669705430
Name:POOLE, CASSIE S (PA-C)
Entity type:Individual
Prefix:
First Name:CASSIE
Middle Name:S
Last Name:POOLE
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 1:200 S MANCHESTER AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3217
Mailing Address - Country:US
Mailing Address - Phone:714-456-3656
Mailing Address - Fax:714-456-8017
Practice Address - Street 1:101 THE CITY DR S
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-456-3656
Practice Address - Fax:714-456-8017
Is Sole Proprietor?:No
Enumeration Date:2009-09-11
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22426363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001537100Medicaid
FL001537100Medicaid