Provider Demographics
NPI:1841760816
Name:CASSIDY, TIMOTHY PAUL JR (NP-C)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:PAUL
Last Name:CASSIDY
Suffix:JR
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 S MARION AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-7064
Mailing Address - Country:US
Mailing Address - Phone:386-438-5722
Mailing Address - Fax:386-438-8631
Practice Address - Street 1:310 S MARION AVE
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-7064
Practice Address - Country:US
Practice Address - Phone:386-438-5722
Practice Address - Fax:386-438-8631
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9227994363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid