Individual
KENNETH R MASSEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PAC
Contact information
Practice address
2723 S 7TH STREET, SUITE A, TERRE HAUTE, IN 47802-3558
(812) 232-8164
(812) 234-6391
Mailing address
5628 PECOS LN, TERRE HAUTE, IN 47805-9686
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
10000863A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
650485596006
CHAMPUS-TRICARE
IN
Enumeration date
08/19/2006
Last updated
05/27/2008
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