Provider Demographics
NPI:1215237979
Name:OTTAVIANO, CASSANDRA MARIE (PA)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:MARIE
Last Name:OTTAVIANO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 MOREHEAD MEDICAL DR STE A
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-2990
Mailing Address - Country:US
Mailing Address - Phone:631-252-3367
Mailing Address - Fax:
Practice Address - Street 1:1021 MOREHEAD MEDICAL DR STE A
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2990
Practice Address - Country:US
Practice Address - Phone:631-252-3367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014296-1363AM0700X
NC0010-11588363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical