Provider Demographics
NPI:1861472375
Name:MASSION, CHARLEA
Entity Type:Individual
Prefix:
First Name:CHARLEA
Middle Name:
Last Name:MASSION
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:PO BOX 1833
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95061-1833
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7600 OLD DOMINION CT
Practice Address - Street 2:
Practice Address - City:APTOS
Practice Address - State:CA
Practice Address - Zip Code:95003-3821
Practice Address - Country:US
Practice Address - Phone:831-458-6200
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45455207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C04294Medicare UPIN