Provider Demographics
NPI:1568003341
Name:MASSEY, MARK WAYNE
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WAYNE
Last Name:MASSEY
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 1:1552 MCGOWAN PKWY
Mailing Address - Street 2:
Mailing Address - City:OLIVEHURST
Mailing Address - State:CA
Mailing Address - Zip Code:95961-9320
Mailing Address - Country:US
Mailing Address - Phone:530-301-2525
Mailing Address - Fax:
Practice Address - Street 1:1552 MCGOWAN PKWY
Practice Address - Street 2:
Practice Address - City:OLIVEHURST
Practice Address - State:CA
Practice Address - Zip Code:95961-9320
Practice Address - Country:US
Practice Address - Phone:530-301-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies