Provider Demographics
NPI:1134490667
Name:MINTON, MASON (LMP)
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:
Last Name:MINTON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 COMMERCE AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3024
Mailing Address - Country:US
Mailing Address - Phone:360-636-3313
Mailing Address - Fax:
Practice Address - Street 1:1151 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3024
Practice Address - Country:US
Practice Address - Phone:360-636-3313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-13
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60219037174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist