MEDICARE: MR. JESSE MASSARO PA

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	363AS0400X	Surgical Physician Assistant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811359102
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JESSE MASSARO PA

Provider Business Mailing Address
First Line	:	2727 W DR MLK BLVD STE 320
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-6055
Country	:	US
Telephone Number	:	813-877-6748
Fax Number	:	813-875-0359

Provider Business Practice Location Address
First Line	:	2727 W DR MARTIN LUTHER KING JR BLVD STE 320
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-6055
Country	:	US
Telephone Number	:	813-877-6748
Fax Number	:	813-875-0359

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

Provider Enumeration Date	:	03/24/2016
Last Update Date	:	04/12/2023

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