Provider Demographics
NPI:1376096602
Name:MASSARO, JOHN MICHAEL
Entity Type:Individual
Prefix:
First Name:JOHN MICHAEL
Middle Name:
Last Name:MASSARO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7900 SHRADER RD
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23294-4215
Mailing Address - Country:US
Mailing Address - Phone:804-288-1953
Mailing Address - Fax:
Practice Address - Street 1:7900 SHRADER RD
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23294-4215
Practice Address - Country:US
Practice Address - Phone:804-288-1953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110005292363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant