Provider Demographics
NPI:1548045446
Name:MASSOCCO, ANDREA L
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:L
Last Name:MASSOCCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6564 EVANS RD
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-8744
Mailing Address - Country:US
Mailing Address - Phone:315-717-1637
Mailing Address - Fax:
Practice Address - Street 1:33 OXFORD RD
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-2637
Practice Address - Country:US
Practice Address - Phone:315-624-1220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006379-01225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant