Provider Demographics
NPI:1558717439
Name:MASOUDI, SOLMAZ
Entity Type:Individual
Prefix:
First Name:SOLMAZ
Middle Name:
Last Name:MASOUDI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 ALLEN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01118-1803
Mailing Address - Country:US
Mailing Address - Phone:413-782-7646
Mailing Address - Fax:413-782-7558
Practice Address - Street 1:1515 ALLEN ST
Practice Address - Street 2:SUITE B
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01118-1803
Practice Address - Country:US
Practice Address - Phone:413-782-7646
Practice Address - Fax:413-782-7558
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA5726363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA043237669Medicaid