Provider Demographics
NPI:1720134810
Name:MASSEY, BLAKE (PA)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:MASSEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 496084
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96049-6084
Mailing Address - Country:US
Mailing Address - Phone:530-222-3287
Mailing Address - Fax:530-222-8547
Practice Address - Street 1:3330 CHURN CREEK RD
Practice Address - Street 2:SUITE D4
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-2532
Practice Address - Country:US
Practice Address - Phone:530-222-3287
Practice Address - Fax:530-222-8547
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15490363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA154900Medicare PIN