Provider Demographics
NPI:1598591489
Name:SHIRLEY, CASSIDY (PA-C)
Entity type:Individual
Prefix:
First Name:CASSIDY
Middle Name:
Last Name:SHIRLEY
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:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:5210 E THOMPSON RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-2085
Practice Address - Country:US
Practice Address - Phone:317-782-7500
Practice Address - Fax:317-782-7515
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
363A00000X
IN10004610A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant