MEDICARE: KENNETH RESHARD MASSEY PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant		MI
2	390200000X	Student in an Organized Health Care Education/Training Program		MI

General Provider Information

NPI Number	:	1437090131
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH RESHARD MASSEY PA-C

Provider Business Mailing Address
First Line	:	3507 GREEN BAY RD APT 208B
Second Line	:
City	:	NORTH CHICAGO
State	:	IL
Zip	:	60064-3658
Country	:	US
Telephone Number	:	313-549-8403
Fax Number	:

Provider Business Practice Location Address
First Line	:	3507 GREEN BAY RD APT 208B
Second Line	:
City	:	NORTH CHICAGO
State	:	IL
Zip	:	60064-3658
Country	:	US
Telephone Number	:	313-549-8403
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2026
Last Update Date	:	04/06/2026

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