Provider Demographics
NPI:1134674682
Name:MASSEY, KACIE JO (PA-C)
Entity Type:Individual
Prefix:
First Name:KACIE
Middle Name:JO
Last Name:MASSEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KACIE
Other - Middle Name:JO
Other - Last Name:BAHR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE
Mailing Address - Street 2:MS 21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-967-7977
Mailing Address - Fax:651-254-8558
Practice Address - Street 1:401 PHALEN BLVD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-5302
Practice Address - Country:US
Practice Address - Phone:952-967-7977
Practice Address - Fax:651-254-8558
Is Sole Proprietor?:No
Enumeration Date:2016-08-24
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12138363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical