Provider Demographics
NPI:1396100194
Name:WEST, CASSIDY (PA-C)
Entity type:Individual
Prefix:
First Name:CASSIDY
Middle Name:
Last Name:WEST
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RR 1 BOX 836
Mailing Address - Street 2:
Mailing Address - City:BOSWELL
Mailing Address - State:OK
Mailing Address - Zip Code:74727-9726
Mailing Address - Country:US
Mailing Address - Phone:580-513-6407
Mailing Address - Fax:
Practice Address - Street 1:410 N M ST
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-1820
Practice Address - Country:US
Practice Address - Phone:580-325-7561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2528363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant