Provider Demographics
NPI:1063749422
Name:MASSON, NICOLE MARIE (PA-C)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:MARIE
Last Name:MASSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3168 BRAVERTON ST
Mailing Address - Street 2:SUITE 340
Mailing Address - City:EDGEWATER
Mailing Address - State:MD
Mailing Address - Zip Code:21037-2674
Mailing Address - Country:US
Mailing Address - Phone:410-956-7777
Mailing Address - Fax:410-956-7186
Practice Address - Street 1:3168 BRAVERTON ST
Practice Address - Street 2:SUITE 340
Practice Address - City:EDGEWATER
Practice Address - State:MD
Practice Address - Zip Code:21037-2674
Practice Address - Country:US
Practice Address - Phone:410-956-7777
Practice Address - Fax:410-956-7186
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDC0004082363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant