Healthcare Provider Details

I. General information

NPI: 1861472375
Provider Name (Legal Business Name): CHARLEA MASSION
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 OLD DOMINION CT
APTOS CA
95003-3821
US

IV. Provider business mailing address

PO BOX 1833
SANTA CRUZ CA
95061-1833
US

V. Phone/Fax

Practice location:
  • Phone: 831-458-6200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG45455
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: