=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609507227
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CASSIE RENEE MASSICOTTE PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2022
-----------------------------------------------------
Last Update Date | 12/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 504 FORT EVANS RD STE 204
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20176-4097
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 135-445-4100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 504 FORT EVANS RD STE 204
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 20176-4097
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-737-3500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 0110009641
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------