Provider Demographics
NPI:1235884040
Name:LOUDERMILK, MASON (NP)
Entity Type:Individual
Prefix:
First Name:MASON
Middle Name:
Last Name:LOUDERMILK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:368 BOONE DRIVE
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165
Mailing Address - Country:US
Mailing Address - Phone:817-888-0995
Mailing Address - Fax:
Practice Address - Street 1:309 REGENCY PKWY STE 101
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5165
Practice Address - Country:US
Practice Address - Phone:682-400-2153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1030504207RG0100X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology