Provider Demographics
NPI:1679344733
Name:CASSIDY, CLAYTON
Entity type:Individual
Prefix:
First Name:CLAYTON
Middle Name:
Last Name:CASSIDY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:879 TERRACESIDE CIR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-6175
Mailing Address - Country:US
Mailing Address - Phone:270-498-0783
Mailing Address - Fax:
Practice Address - Street 1:5979 DESERT STORM AVE
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5514
Practice Address - Country:US
Practice Address - Phone:270-498-0783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-09
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant