Basic Information
| Provider Information | |||||||||
| NPI: | 1285870337 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASSIDY | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ACNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WAGNER | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ACNP-BC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8328 E HARTFORD DR | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802149720 | ||||||||
| FaxNumber: | 4802149722 | ||||||||
| Practice Location | |||||||||
| Address1: | 8328 E HARTFORD DR | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4802149720 | ||||||||
| FaxNumber: | 4802149722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/19/2008 | ||||||||
| LastUpdateDate: | 04/07/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 13869 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363L00000X | AP3853 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 581885 | 05 | AZ | MEDICAID |