Provider Demographics
NPI:1912697848
Name:LAX, KASSIDY
Entity Type:Individual
Prefix:
First Name:KASSIDY
Middle Name:
Last Name:LAX
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 1:2917 FISCHER RD
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18045-2414
Mailing Address - Country:US
Mailing Address - Phone:484-426-6039
Mailing Address - Fax:
Practice Address - Street 1:2917 FISCHER RD
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18045-2414
Practice Address - Country:US
Practice Address - Phone:484-426-6039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-12
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP027470363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily