Basic Information
Provider Information | |||||||||
NPI: | 1417138355 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MASSEY HAND AND PLASTIC SURGERY LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1951 N WILMOT RD | ||||||||
Address2: | BLDG 2 | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857128000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5207507166 | ||||||||
FaxNumber: | 5208861929 | ||||||||
Practice Location | |||||||||
Address1: | 3170 N SWAN RD | ||||||||
Address2: |   | ||||||||
City: | TUCSON | ||||||||
State: | AZ | ||||||||
PostalCode: | 857121227 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5202982325 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/20/2007 | ||||||||
LastUpdateDate: | 04/07/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MASSEY | ||||||||
AuthorizedOfficialFirstName: | BRANDON | ||||||||
AuthorizedOfficialMiddleName: | ZELPH | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 5202982325 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 35576 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 115539 | 05 | AZ |   | MEDICAID |