Provider Demographics
NPI:1538324751
Name:MASSIE, CORNELIA ALYSIA (MD)
Entity Type:Individual
Prefix:
First Name:CORNELIA
Middle Name:ALYSIA
Last Name:MASSIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CORNELIA
Other - Middle Name:ALYSIA
Other - Last Name:STAHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-333-8883
Mailing Address - Fax:
Practice Address - Street 1:825 NICOLLET MALL
Practice Address - Street 2:SUITE 300
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-2606
Practice Address - Country:US
Practice Address - Phone:612-333-8883
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN52605207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN110014483Medicare PIN