MEDICARE: MASSA KEITA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	PN302295	PA

General Provider Information

NPI Number	:	1417582396
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MASSA KEITA

Provider Business Mailing Address
First Line	:	6800 GUYER AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19142-2519
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6800 GUYER AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19142-2519
Country	:	US
Telephone Number	:	267-580-3136
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/11/2020
Last Update Date	:	03/11/2020

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Directions to “ MASSA KEITA ” Practice Location

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