Provider Demographics
NPI:1588779706
Name:CASSELLA, TINA M (ARNP)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:M
Last Name:CASSELLA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 6TH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-3222
Mailing Address - Country:US
Mailing Address - Phone:913-682-5588
Mailing Address - Fax:913-682-2698
Practice Address - Street 1:1001 6TH AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-3222
Practice Address - Country:US
Practice Address - Phone:913-682-5588
Practice Address - Fax:913-682-2698
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KS44644207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100318140BMedicaid
KS100318140BMedicaid
KSP63512Medicare UPIN