Provider Demographics
NPI:1730567785
Name:CASSIDY, COLIN
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:
Last Name:CASSIDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 N LYON ST
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020-1306
Mailing Address - Country:US
Mailing Address - Phone:585-409-6630
Mailing Address - Fax:
Practice Address - Street 1:8 N LYON ST
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-1306
Practice Address - Country:US
Practice Address - Phone:585-409-6630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009745-1225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY009745-1OtherLICENSE #