Provider Demographics
NPI:1568627917
Name:MASTERSON, LARRY LEE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:LEE
Last Name:MASTERSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 MAIN STREET SPRINGFIELD MEDICAL ASSOC. INC.
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104
Mailing Address - Country:US
Mailing Address - Phone:413-739-5676
Mailing Address - Fax:413-733-5860
Practice Address - Street 1:2150 MAIN STREET SPRINGFIELD MEDICAL ASSOC. INC.
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104
Practice Address - Country:US
Practice Address - Phone:413-739-5676
Practice Address - Fax:413-733-5860
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT533363A00000X
MAPA5547363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT720443Medicaid
MT000085097Medicare PIN