Provider Demographics
NPI:1174140404
Name:MASSIE, NICHOLAS
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:MASSIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 CRABAPPLE DR
Mailing Address - Street 2:
Mailing Address - City:HOWARD
Mailing Address - State:OH
Mailing Address - Zip Code:43028-8038
Mailing Address - Country:US
Mailing Address - Phone:937-926-1208
Mailing Address - Fax:
Practice Address - Street 1:221 DUFF ST
Practice Address - Street 2:
Practice Address - City:GAMBIER
Practice Address - State:OH
Practice Address - Zip Code:43022-5013
Practice Address - Country:US
Practice Address - Phone:937-926-1208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART006173207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine