Healthcare Provider Details

I. General information

NPI: 1902069933
Provider Name (Legal Business Name): NICOLE M MASIAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 06/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MAGNOLIA AND FIFTH STREET BUILDING 6
MOUNTAIN HOME TN
37684
US

IV. Provider business mailing address

BOX 70431 WILLIAM L. JENKINS FORENSIC CENTER, ETSU/QUILLEN COM
JOHNSON CITY TN
37614
US

V. Phone/Fax

Practice location:
  • Phone: 423-439-8038
  • Fax: 423-439-8070
Mailing address:
  • Phone: 423-439-8038
  • Fax: 423-439-8070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number0101248381
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: