Provider Demographics
NPI:1881951457
Name:MASSARI, DOMENIQUE (PA-C)
Entity type:Individual
Prefix:
First Name:DOMENIQUE
Middle Name:
Last Name:MASSARI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10131 FOREST HILL BLVD STE 230
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6109
Mailing Address - Country:US
Mailing Address - Phone:561-798-6600
Mailing Address - Fax:561-615-1958
Practice Address - Street 1:460 N STATE ROAD 7 STE 300
Practice Address - Street 2:
Practice Address - City:ROYAL PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33411-3514
Practice Address - Country:US
Practice Address - Phone:561-798-6600
Practice Address - Fax:561-753-3328
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106282363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant