Healthcare Provider Details

I. General information

NPI: 1962607200
Provider Name (Legal Business Name): BRENDAN DAVID MASINI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE
TACOMA WA
98431-4613
US

IV. Provider business mailing address

5110 57TH AVE NW
GIG HARBOR WA
98335-7385
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-1581
  • Fax:
Mailing address:
  • Phone: 210-632-6429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number24038
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberDR.0054168
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number24038
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: