Healthcare Provider Details

I. General information

NPI: 1265242416
Provider Name (Legal Business Name): MASROQUE MUSA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2025
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 CRAFTS ST STE 400
NEWTON MA
02458-1393
US

IV. Provider business mailing address

29 CRAFTS ST STE 400
NEWTON MA
02458-1393
US

V. Phone/Fax

Practice location:
  • Phone: 617-964-7530
  • Fax:
Mailing address:
  • Phone: 617-964-7530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA102545
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: