Provider Demographics
NPI:1982171377
Name:CASSIDY, BRIANNE KATHLEEN
Entity Type:Individual
Prefix:
First Name:BRIANNE
Middle Name:KATHLEEN
Last Name:CASSIDY
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 1:13851 E 14TH ST STE 203
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-2627
Mailing Address - Country:US
Mailing Address - Phone:510-614-9200
Mailing Address - Fax:
Practice Address - Street 1:13690 E 14TH ST STE 230
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2584
Practice Address - Country:US
Practice Address - Phone:510-614-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55848363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical