1356521306 NPI number — CASSANDRA L NETT PA-C

Table of content: CASSANDRA L NETT PA-C (NPI 1356521306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356521306 NPI number — CASSANDRA L NETT PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NETT
Provider First Name:
CASSANDRA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
L'HUILLIER
Provider Other First Name:
CASSANDRA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1356521306
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 735044
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60673-5044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-326-2250
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2414 KOHLER MEMORIAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHEBOYGAN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53081-3129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-457-4461
Provider Business Practice Location Address Fax Number:
920-459-1152
Provider Enumeration Date:
11/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  5601005663 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 222123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 41949400 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00835229 . This is a "RR MEDICARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 0152200130 . This is a "BCBS MI" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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