Provider Demographics
NPI:1720327869
Name:WELLOCK, CASSIE ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:CASSIE
Middle Name:ANN
Last Name:WELLOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1155 MILL ST MS M14
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1576
Mailing Address - Country:US
Mailing Address - Phone:775-982-4876
Mailing Address - Fax:775-982-3900
Practice Address - Street 1:1525 LOS ALTOS PKWY
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89436-6692
Practice Address - Country:US
Practice Address - Phone:775-982-5000
Practice Address - Fax:775-982-3900
Is Sole Proprietor?:No
Enumeration Date:2013-02-09
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1396363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV12788722OtherCAQH ID #
NVPA1396OtherPAC LIC #