Provider Demographics
NPI:1477090678
Name:MASON, ROB (LPN)
Entity Type:Individual
Prefix:
First Name:ROB
Middle Name:
Last Name:MASON
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:ROB
Other - Middle Name:
Other - Last Name:MASON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:1800 N JAMES H MCGEE BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45417-9526
Mailing Address - Country:US
Mailing Address - Phone:937-262-5905
Mailing Address - Fax:937-262-3518
Practice Address - Street 1:1800 N JAMES H MCGEE BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45417-9526
Practice Address - Country:US
Practice Address - Phone:937-262-5905
Practice Address - Fax:937-262-3518
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN139992-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9374756755Medicaid