Provider Demographics
NPI:1164537445
Name:MASSEY, BRAD H (AACNP, ANP)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:H
Last Name:MASSEY
Suffix:
Gender:M
Credentials:AACNP, ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:348 KNIGHT ROAD
Mailing Address - Street 2:
Mailing Address - City:SUMRALL
Mailing Address - State:MS
Mailing Address - Zip Code:39482
Mailing Address - Country:US
Mailing Address - Phone:601-606-6326
Mailing Address - Fax:
Practice Address - Street 1:348 KNIGHT RD
Practice Address - Street 2:
Practice Address - City:SUMRALL
Practice Address - State:MS
Practice Address - Zip Code:39482-3702
Practice Address - Country:US
Practice Address - Phone:601-606-6326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR814032363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS640507572POOtherAMERICAN ADMIN GROUP
LA1582531Medicaid
MS00124846Medicaid
LA1582531Medicaid
MS512I500756Medicare PIN
MS512I500756Medicare PIN