Provider Demographics
NPI:1083785695
Name:MASIONGALE, AMY JO (CRNA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JO
Last Name:MASIONGALE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8717 W 110TH ST STE 600
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-2126
Mailing Address - Country:US
Mailing Address - Phone:913-428-2900
Mailing Address - Fax:913-428-2951
Practice Address - Street 1:2100 SE BLUE PKWY
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64063
Practice Address - Country:US
Practice Address - Phone:913-428-2900
Practice Address - Fax:913-428-2951
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2019-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS43-557644367500000X
GARN101263367500000X
MO2018044045367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA339446OtherWELLCARE CMO
GA430079467OtherRRMEDICARE
SCGAN227Medicaid
GA000731607CMedicaid
GA000731607DMedicaid
GA550789920OtherTRICARE
GA550789920OtherTRICARE