Basic Information
| Provider Information | |||||||||
| NPI: | 1649680364 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MASSEY | ||||||||
| FirstName: | MARC | ||||||||
| MiddleName: | K | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8010 POCKET RD APT 296 | ||||||||
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| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958315750 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2066042080 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1800 N CALIFORNIA ST, STOCKTON, CA | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099432000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2014 | ||||||||
| LastUpdateDate: | 02/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 57099 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.