Provider Demographics
NPI:1790171841
Name:MASSOUD, JEREMY JAMES
Entity Type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:JAMES
Last Name:MASSOUD
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 1:800 IRVING AVE
Mailing Address - Street 2:VETERANS AFFAIRS MEDICAL CENTER
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210
Mailing Address - Country:US
Mailing Address - Phone:720-236-7138
Mailing Address - Fax:
Practice Address - Street 1:800 IRVING AVE
Practice Address - Street 2:VETERANS AFFAIRS MEDICAL CENTER
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210
Practice Address - Country:US
Practice Address - Phone:720-236-7138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-15
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6883851163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse