Provider Demographics
NPI:1699495770
Name:WILLIAMS, KASSANDRA (PA-C)
Entity type:Individual
Prefix:
First Name:KASSANDRA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KASSANDRA
Other - Middle Name:
Other - Last Name:HEREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:10012 KENNERLY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-2197
Mailing Address - Country:US
Mailing Address - Phone:309-265-7877
Mailing Address - Fax:
Practice Address - Street 1:10012 KENNERLY RD STE 300
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2197
Practice Address - Country:US
Practice Address - Phone:309-265-7877
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022039976363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant