MEDICARE: CASSIE RENEE MASSICOTTE PA-C

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	390200000X	Student in an Organized Health Care Education/Training Program
2	363A00000X	Physician Assistant	0110009641	VA

General Provider Information

NPI Number	:	1609507227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASSIE RENEE MASSICOTTE PA-C

Provider Business Mailing Address
First Line	:	504 FORT EVANS RD STE 204
Second Line	:
City	:	LEESBURG
State	:	VA
Zip	:	20176-4097
Country	:	US
Telephone Number	:	703-737-3500
Fax Number	:

Provider Business Practice Location Address
First Line	:	504 FORT EVANS RD STE 204
Second Line	:
City	:	LEESBURG
State	:	VA
Zip	:	20176-4097
Country	:	US
Telephone Number	:	135-445-4100
Fax Number	:

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

Provider Enumeration Date	:	06/23/2022
Last Update Date	:	12/01/2023

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