Provider Demographics
NPI:1114600848
Name:COCHRAN, MASON (PTA)
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:
Last Name:COCHRAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5920 PRIVATE ROAD 1604
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-5371
Mailing Address - Country:US
Mailing Address - Phone:417-372-3614
Mailing Address - Fax:
Practice Address - Street 1:1111 N KENTUCKY AVE
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2028
Practice Address - Country:US
Practice Address - Phone:417-257-5959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023028649225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant