Provider Demographics
NPI:1811454051
Name:MASSERIA, MICHAEL KENNETH (CRNA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KENNETH
Last Name:MASSERIA
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Gender:
Credentials:CRNA
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Mailing Address - Street 1:STONY BROOK UNIVERSITY MEDICAL CENTER
Mailing Address - Street 2:HSC LEVEL 4 - ROOM 060
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8480
Mailing Address - Country:US
Mailing Address - Phone:631-444-2975
Mailing Address - Fax:
Practice Address - Street 1:STONY BROOK UNIVERSITY MEDICAL CENTER
Practice Address - Street 2:HSC LEVEL 4 - ROOM 060
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8480
Practice Address - Country:US
Practice Address - Phone:631-444-2975
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2025-03-12
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Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY431879363LA2100X
NY686773367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care