Provider Demographics
NPI:1083044473
Name:MASK, CODY ALLYN
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:ALLYN
Last Name:MASK
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 1:4890 32ND AVE SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97317-9350
Mailing Address - Country:US
Mailing Address - Phone:503-588-5647
Mailing Address - Fax:503-599-0509
Practice Address - Street 1:4890 32ND AVE SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97317-9350
Practice Address - Country:US
Practice Address - Phone:503-588-5647
Practice Address - Fax:503-599-0509
Is Sole Proprietor?:No
Enumeration Date:2013-11-21
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker