Provider Demographics
NPI:1942062302
Name:MASSA, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:MASSA
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 1:4001 THE FAIRWAY
Mailing Address - Street 2:
Mailing Address - City:CALVERTON
Mailing Address - State:NY
Mailing Address - Zip Code:11933-1372
Mailing Address - Country:US
Mailing Address - Phone:631-413-5955
Mailing Address - Fax:
Practice Address - Street 1:301 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8408
Practice Address - Country:US
Practice Address - Phone:631-968-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant