MEDICARE: MS. WHOOPI TENNEH MASSAQUOI

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	363A00000X	Physician Assistant	TP8827	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	TP8827	OTHER	AZ	AAPA

General Provider Information

NPI Number	:	1518514413
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. WHOOPI TENNEH MASSAQUOI

Provider Business Mailing Address
First Line	:	4700 N 51ST AVE STE 4
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85031-1295
Country	:	US
Telephone Number	:	623-846-7575
Fax Number	:	623-836-3778

Provider Business Practice Location Address
First Line	:	4700 N 51ST AVE STE 4
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85031-1295
Country	:	US
Telephone Number	:	623-846-7575
Fax Number	:	623-836-3778

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

Provider Enumeration Date	:	08/25/2019
Last Update Date	:	12/28/2021

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