Healthcare Provider Details

I. General information

NPI: 1578375325
Provider Name (Legal Business Name): AUSTIN THOMAS MASSOLIO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/20/2025
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9800 S HEALTHPARK DR STE 200
FORT MYERS FL
33908-3630
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-481-4111
  • Fax:
Mailing address:
  • Phone: 239-343-8260
  • Fax: 239-343-4258

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: