Provider Demographics
NPI:1316581093
Name:ROSSER, CASSANDRA Y
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:Y
Last Name:ROSSER
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:PO BOX 46323
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72214-6323
Mailing Address - Country:US
Mailing Address - Phone:732-300-6889
Mailing Address - Fax:
Practice Address - Street 1:8404 RUSSWOOD LN W
Practice Address - Street 2:
Practice Address - City:MABELVALE
Practice Address - State:AR
Practice Address - Zip Code:72103-4283
Practice Address - Country:US
Practice Address - Phone:732-300-6889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR171W00000X
171WH0202X, 332B00000X, 332BD1200X, 332BX2000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No171W00000XOther Service ProvidersContractorGroup - Multi-Specialty
No171WH0202XOther Service ProvidersContractorHome Modifications
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BD1200XSuppliersDurable Medical Equipment & Medical SuppliesDialysis Equipment & Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & SuppliesGroup - Multi-Specialty